Professor Yin Huihe on Treatment Principles for Jiju Masses and Guzhang Abdominal Distension

In Professor Yin Huihe's Zhongyi Neike Xinlun (New Discourse on TCM Internal Medicine), Professor Yin specifically discusses the treatment of jiju (accumulations and gatherings) and guzhang (abdominal distension). The jiju of TCM encompasses modern tumors of the gastrointestinal tract and the female reproductive organs, while guzhang mostly corresponds to ascites caused by cirrhosis or advanced cancer.

Under the entry for jiju, Professor Yin writes as follows: "Subcostal accumulated masses arise mainly from qi stagnation and blood stasis; the disease pertains to the liver (note: the TCM liver is a different concept from the liver of modern medicine), since this is the region traversed by the liver's channel. Some cases arise from prolonged jaundice that does not resolve; others arise from gu poison, excessive drinking, or long-standing hypochondriac pain that enters the collaterals. The disease usually begins as blood stasis presenting as an accumulated mass; in severe cases the pain becomes fixed and does not move, and then a feeling of fullness and distension is constantly present in the epigastrium, chest, and hypochondria."

The above description closely resembles the clinical picture of middle-to-late-stage gastrointestinal or gynecological tumors. For such patients, Professor Yin advocated combining the treatment of moving blood and resolving stasis with that of softening hardness and dispersing accumulation. He commonly used Danshen, Chishao, Mudanpi, Danggui, Yujin, Jianghuang, Taoren, Honghua, Yanhusuo, Sanleng, Ezhu, Wulingzhi and the like to activate blood and resolve stasis; Chaihu, Qingpi, Zhiqiao, Xiangfu, Chuanlianzi, Wuyao, Houpo, Muxiang, Chenpi, Sharen and the like to soothe the liver and move qi; and Biejia (Trionycis Carapax), Muli (Ostrea Concha), Walengzi (Arcae Concha), Tubiechong (Eupolyphaga), Shuizhi (Hirudo), Mengchong (Tabanus), Haifushi, Ganqi (processed Lacquer), Qicao, Qianglang and the like to resolve stasis and soften hardness. He also advised appropriately blending in some phlegm-damp herbs and righteous-qi-tonifying herbs.

Under the entry for guzhang, Professor Yin held that "the development of guzhang always comes down to three factors: blood stasis, qi stagnation, and retained fluid. On the surface it seems that 'no water, no guzhang,' so water should be the main target; in fact, however, the reason water can accumulate in the abdominal cavity itself arises from blood stasis and qi stagnation."

Thus, in treating guzhang, Professor Yin advocated using not only the herbs used for jiju but also herbs that treat water and dampness. He emphasized increasing herbs that move qi and drain water, especially those that open lung qi and free the sanjiao, such as Jiegeng (Platycodi Radix), Ziwan (Asteris Radix), Pipaye (Eriobotryae Folium), Jiaomu (Zanthoxyli Fructus), Tinglizi (Descurainiae Semen), Dafupi (Arecae Pericarpium), Binglang (Arecae Semen), Fuling (Poria), Zexie (Alismatis Rhizoma), Cheqianzi (Plantaginis Semen), Fangji (Stephaniae Tetrandrae Radix), Chen Hulu, Tu Gou, Xishuai. Professor Yin did not favor lightly using highly toxic herbs such as Qianniuzi (Pharbitidis Semen), Daji (Euphorbiae Pekinensis Radix), Yuanhua (Genkwa Flos), or Gansui (Kansui Radix); if these had to be used, they should be paired with Renshen, Huangqi, Baizhu, and Dazao, combining support of the righteous with expulsion of the pathogen.

Both jiju and guzhang are, in TCM, severe and difficult—or even incurable—internal diseases. In clinical practice, when major diseases such as cirrhosis and tumors progress to the stage of pleural and ascitic fluid, they are indeed very intractable, though not without a ray of hope. In my view, Professor Yin's discussion of jiju and guzhang is precise, and his medication guidance is very much on point.

Whether or not ascites has yet developed, middle-to-late-stage malignant tumors can produce ascites at any time. Treating ascites by diuresis alone does not work. One must combine blood-activating, stasis-resolving herbs with qi-moving, stagnation-discharging herbs and hardness-softening, nodule-dispersing herbs in order to address both root and manifestation, and even then there may be only a thin chance.

In my experience, however, patients who have taken water-draining herbs for too long develop resistance to the diuretic effects of both Chinese and Western drugs. Some patients respond to water-draining herbs for a time, but after a while the same herbs no longer work.

Jiju and guzhang also have the feature that the patient's abdominal distension is quite severe, making it hard to eat or drink. Therefore, when prescribing for such patients, one should follow the principle of strong force and focused effect, keeping the formula leaner, with moderately larger individual doses. First resolve the abdominal distension, and only then address other aspects, broadening the prescription.

Some physicians also treat jiju and guzhang by transdermal delivery through the umbilicus; this is also a valuable clinical approach. For patients who can barely take in food or water, transdermal umbilical delivery may offer a ray of hope.