Annotated Reading of the "Breast Cancer" and "Breast Nodule" Chapters in Ma Peizhi's Surgical Cases

Ma Peizhi was a famous TCM physician of the late Qing Dynasty, especially skilled in TCM external medicine. He studied medicine for sixteen years under his grandfather Ma Shengsan; because of his strong memory, wide reading and visits to famous teachers, his art was profound and his results outstanding. Patients came from far and wide, so that boats never ceased at the Menghe wharf of his small town, inns were full, and more than a hundred people sought treatment each day—for fifty years.

In his later years, Ma Peizhi was summoned by the Qing court to be an imperial physician, but after one year he repeatedly resigned and returned home to continue treating the common people. Before his death, Ma Peizhi wrote a book, Yilve Cunzhen, which was unfortunately never published. Later his secondary disciple Fan Fengyuan organized his posthumous writings and medical cases into the book Ma Peizhi's Surgical Cases, bringing his experience in treating external diseases to light. This article offers an annotated reading of the chapters "Breast Cancer" and "Breast Nodule" in that book.

Ma Peizhi's Chapter on "Breast Cancer"

The nipple belongs to the liver; the breast belongs to the stomach; the stomach is linked to the spleen. The condition of breast cancer arises from brooding and depression, injury to both liver and spleen, anxious thoughts lodged in the heart, unfulfilled wishes and thwarted will, drying and sluggishness of the channels, and binding of phlegm and qi. A tubercle in both breasts that has lasted for years becomes pulling pain that radiates. Liver yin is also damaged, qi transforms into fire, and depressive phlegm in Yangming does not clear; fearing it will grow into cancer, he should quickly cast aside worldly cares, open his heart and resolve depression, so that it may be dispelled—this would be auspicious. I propose a formula for your consideration:

American Ginseng (Xiyangshen), Cyperus (Xiangfu, processed in child's urine), Honey-fried Green Tangerine Peel (Qingpi), Sichuan Fritillary (Chuanbeimu), Whole Trichosanthes (Gualou), Red and White Peony, Mushroom (Maogu), Tangerine Peel (Chenpi), Selfheal Spike (Xiakucao), clear Pinellia (Qing Banxia), Chinese Angelica (Danggui), Eupatorium Leaf (Peilan Ye), Red Jujube.

Breast cancer has ulcerated; the breast is hard-swollen with pulling pain, and there is certainly the risk of cauliflower-like growth and bleeding. This is a refractory condition; I tentatively propose nourishing yin and clearing the liver:

Raw Rehmannia (Sheng Di), Chinese Angelica (Danggui), White Peony (Baishao), Gardenia (Heizhi), raw Licorice (Shenggancao), Antelope Horn (Lingyang Pian), Moutan (Danpi), Trichosanthes (Gualou), Great Fritillary (Da Beimu), Forsythia (Lianqiao), Dandelion (Pugongying).

Breast cancer for one year; the swelling protrudes red and purple, has just ulcerated two days, with pulling pain in the channels. This is refractory; I reluctantly propose nourishing yin and clearing the liver:

Northern Glehnia (Bei Shashen), Ophiopogon (Maidong), Great Fritillary (Da Beimu), Moutan (Danpi), Chinese Angelica (Danggui), Antelope Horn (Lingyang Pian), Gardenia (Heizhi), Forsythia (Lianqiao), Licorice (Gancao), Ze Lan, Selfheal Spike (Xiakucao), Lotus Root (Ou).

Liver depression with breast nodule; qi transforms into fire. Drawing, pulling pain—fear that it will ripen into the great affliction of breast cancer. Liver-Clearing Decoction (Qinggan Tang) should govern:

Chinese Angelica (Danggui), Trichosanthes (Gualou), Moutan (Danpi), Selfheal Spike (Xiakucao), Forsythia (Lianqiao), Great Fritillary (Da Beimu), black Gardenia (Shanzhi), Ze Lan, Northern Glehnia (Bei Shashen), White Peony (Baishao), Calamondin Leaf (Jinju Ye).

Blood fails to nourish the liver; liver qi is depressed; the right breast is swollen and hard, the nipple pulls with pain, trending toward cancer. Urgently clear the liver and resolve depression, hoping to dispel it:

Whole Trichosanthes (Gualou), Green Tangerine Peel (Qingpi), Licorice (Gancao), Atractylodes (Baizhu), Mint (Bohe), Chinese Angelica (Danggui), Bupleurum (Chaihu), White Peony (Baishao), Gardenia (Heizhi), Moutan (Danpi), Dandelion (Pugongying), Tangerine Leaf (Ju Ye).

Sudden rage injures yin. Jueyin qi-fire is exuberant and joins with Yangming phlegm-heat in the collaterals, so the breast is hard-swollen and several nodules hang in a row along the neck, sometimes pulling with pain; this has already become cancer. The right pulse is rapid and flooding; fire qi does not descend. Beware of ulceration; urgently nourish yin and clear the liver:

Antelope Horn (Lingyang Pian), Asparagus (Tianmen Dong), Whole Trichosanthes (Gualou), Great Fritillary (Da Beimu), Moutan (Danpi), Gardenia (Heizhi), fresh Dendrobium (Shan Shihu), Forsythia (Lianqiao), Ze Lan, Red Peony (Chishao), dark Scrophularia (Hei Xuanshen), Dandelion (Pugongying).

Qi deficiency generates phlegm; yin deficiency generates heat. Qi-fire, carrying phlegm, joins in the collaterals. The breast cancer is markedly swollen, paining as if bitten by insects. This is yang transforming internal wind that stirs restlessly. On gloomy days the chest feels stuffy. Yin is deficient and fluids dry; nourish yin, clear qi and resolve phlegm, planning gradually:

Asparagus (Tian Dong), Antelope (Lingyang), Silktree Albizia Flower (Yehe Hua), Tangerine Leaf (Ju Ye), Curcuma (Yujin), Jellyfish (Haizhe), Trichosanthes Seed (Gualou Ren), Poria (Fuling), Sichuan Fritillary (Chuanbeimu), Ze Lan, Forsythia (Lianqiao), Water Chestnut (Biqi).

The pulling pain of the breast nodule has lessened. Liver fire not yet cleared; the pulse is still wiry and rapid. Continue the previous method:

Whole Trichosanthes (Gualou), White Peony (Baishao), Chinese Angelica (Danggui), Moutan (Danpi), Selfheal Spike (Xiakucao), Forsythia (Lianqiao), Northern Glehnia (Bei Shashen), Great Fritillary (Da Beimu), Gardenia (Heizhi), Ze Lan, Silktree Albizia Flower (Hehuan Hua), Tangerine Leaf (Ju Ye).

Liver qi, carrying phlegm; a tubercle in the left breast for over three months. Fortunately it has not pained; it can be hoped to disperse. Clear the liver and dissipate nodules:

Chinese Angelica (Danggui), Bupleurum (Chaihu), Forsythia (Lianqiao), Red Peony (Chishao), Cyperus (Xiangfu), Striated Silkworm (Jiangcan), Green Tangerine Peel (Qingpi), Great Fritillary (Da Beimu), Selfheal Spike (Xiakucao), Trichosanthes (Gualou), Dandelion (Pugongying), Tangerine Leaf (Ju Ye).

Ma Peizhi's Chapter on Breast Nodules (Ruhe)

Breast cancer and breast nodules occur in both men and women, but are more common in women and harder to treat. The nipple is the convergence of the liver and kidney channels; the breast is where Yangming qi and blood gather. In terms of condition, the nodule is mild and the cancer severe; in terms of form, the nodule is small and the cancer large. The nodule is like scrofula of the neck, round or flat, movable on pushing; the cancer is like craggy rock, now sunken now raised, as if the tendons were contracted—all caused by liver-spleen depression. Phlegm and qi congealing produce the nodule; qi-fire binding produces the cancer. The nodule is painful where it is hard; the cancer is not painful where it is hard, but the surrounding channels pull with pain. To treat the nodule, resolve depression and transform phlegm:

Gardenia (Shanzhi, salt-fried), Cyperus (Xiangfu, ginger-juice fried), Sichuan Lovage (Chuanxiong), Peach Kernel (Taoren), Rehmannia (Shengdi), Atractylodes (Baizhu), Chinese Angelica (Danggui), Platycodon (Jiegeng), Asparagus (Tian Dong), Ophiopogon (Maidong), Trichosanthes Root (Tianhuafen), Polygala (Yuanzhi), Pinellia (Banxia), Fritillary (Beimu), Akebia (Mutong).

To treat cancer, resolve depression and clear the liver:

Cyperus (Xiangfu, ginger-juice fried), Peach Kernel (Taoren), Sichuan Lovage (Chuanxiong), Chinese Angelica (Danggui), Mint (Bohe), Gardenia (Shanzhi), Green Tangerine Peel (Qingpi), White Peony (Baishao), Moutan (Danpi), Achyranthes (Niuxi), Antelope Horn (Lingyangjiao), Chaenomeles (Mugua), Bupleurum (Chaihu), Gentiana Longdancao (Longdancao, wine-fried), Atractylodes (Baizhu), Akebia (Mutong), Fritillary (Beimu), Scutellaria (Huangqin), Alisma (Zexie), Trichosanthes Root (Tianhuafen), Eclonia (Kunbu), Sargassum (Haizao).

Then examine the pulse's deficiency/excess and the body's strength; for the deficient, slightly add gentle tonification:

Glehnia (Shashen), Polygala (Yuanzhi), Ophiopogon (Maidong), Arborvitae Seed (Baiziren), Chinese Yam (Shanyao).

to support the righteous. Chen Shizong wanted to use moxibustion and needling; this is the method for breast carbuncle (ruyong), not the method for breast cancer or breast nodule. Breast cancer and breast nodules must absolutely not be needled; if needled they will surely worsen and quickly. The Quansheng Ji wants to use Yanghe Wan; this treats deficiency-cold disease, not disease bound by depressive fire. Depressive fire is at its height; for a short while it must not be classed as a yin abscess. The best course is, when breast cancer is first noticed, to immediately use dispersing:

Striated Silkworm (Jiangcan), White Peony (Baishao), Dandelion (Pugongying), Whole Trichosanthes (Gualou), Forsythia (Lianqiao), Selfheal Spike (Xiakucao), Sichuan Fritillary (Chuanbeimu), Scrophularia (Xuanshen), Gardenia (Shanzhi), Cyperus (Xiangfu), Chinese Angelica (Danggui), Antelope Tip (Lingyang Jian), Cremastra (Mao Cigu), Green Tangerine Peel (Qingpi), Tangerine Leaf (Ju Ye), Ze Lan, Bupleurum (Chaihu), Solanum Dulcamara (Shu Yangquan).

If dispersing does not respond, the patient must broaden the mind and nurture herself, treating according to symptoms; this may still prolong life for a while. If there is pulling pain, it means depressive fire is stirring internally; urgently give liver-clearing depression-resolving medicine, and externally apply Qinghua Gao (Clear-Transformation Paste).

Qinghua Gao: fresh Rehmannia (Shengdi) half a jin, rapeseed oil one jin, yellow wax one liang.

First decoct the Rehmannia in the rapeseed oil until it withers, remove the dregs, add the yellow wax to melt and set the paste. Yet though medicines are tasted, in the end nothing can help against the impact of emotions.

Again, breast cancer is an injury caused by the seven emotions, arising from grief, brooding, depression and rage, with qi accumulating in liver and stomach. Qi stagnates in the channels, so the network vessels do not pass, and blood correspondingly congeals. Depression over long time transforms to fire; the swelling hardens and pulls with pain. It is not an abscess for which attacking or tonifying methods may be used. Alas, physicians take breast carbuncle as excess and breast cancer as deficiency, rigidly using Ginseng and Atractylodes to stagnate the qi; with qi exuberant, fire blazes all the more—how can it not ulcerate? Over the years, of the ulcerated cases I have seen, the majority were ruined by tonics or by Yanghe Tang; hence I repeat this warning for later students.

Note by Zhiyuan: Ma Peizhi's chapters "Breast Cancer" and "Breast Nodule" are the essence of his experience in treating breast cancer, breast tubercles and related conditions. Ma Peizhi took a critical attitude toward Yanghe Tang in Wang Hongxu's Quansheng Ji; this was Ma Peizhi's personal bias. Modern TCM scholars have confirmed through animal experiments that Yanghe Tang is effective against breast cancer. Hebei Medical University once published a report by a certain Tian on animal experimental study of Yanghe Tang in treating breast cancer; by experimenting on tumor-bearing mice and analyzing the data, Mr. Tian drew the following three conclusions:

1. Yanghe Tang has no estrogen-like effect; on the contrary, it inhibits the growth and development of the uterus and ovaries in weanling mice, showing a negative dose-response relationship within a certain dose range. 2. Yanghe Tang inhibits both MCF-7 and MDA-MB-231 cells in a dose- and time-dependent manner, affects cell-cycle distribution and induces tumor apoptosis. However, its inhibitory and killing effect on ER(-) MDA-MB-231 cells is far stronger than on ER(+) MCF-7 cells. 3. Yanghe Tang can be used to treat breast cancer, but it is more suitable for ER(-) breast cancer patients.

Yet Ma Peizhi did have original insights in treating breast cancer; modern TCM treatment of breast cancer still largely follows his approach. Mr. Tian's research also confirmed that Ma Peizhi's argument was partly correct: Yanghe Tang is only suitable for ER-negative and not for ER-positive breast cancer patients. The herbs Ma Peizhi commonly used—Trichosanthes, Trichosanthes Root, Gardenia, Cyperus and others—have also been shown by modern pharmacology to genuinely inhibit tumor progression in breast cancer.

Ma Peizhi's understanding of the cause of breast cancer emphasized that it is caused by internal injury from the seven emotions, and he opposed the indiscriminate use of tonics by breast cancer patients. Modern pathology, however, confirms that breast cancer is not entirely emotional in origin; some cases are genetic. Moreover, today's TCM breast-cancer patients differ from those in Ma Peizhi's day: modern patients usually first undergo Western surgery, radiotherapy and chemotherapy before seeking TCM. At that point, TCM should also not be rigid; it should still emphasize supporting the righteous.