Appreciating Dr. Zhang Xijun's Case of Treating a Mediastinal Tumor with Pleural Effusion
Dr. Zhang Xijun was born in 1913 and was a native of Wuxi, Jiangsu Province. He began practicing medicine formally in 1930 and accumulated more than fifty years of clinical experience over his lifetime. He served as director of the First and Second TCM Hospitals of Chongqing. Dr. Zhang treated countless patients and saved many critically ill ones. This article introduces one of his medical cases: treating a mediastinal tumor with pleural effusion by the method of dissipating phlegm and stasis, scattering nodules and promoting urination.
The patient, a woman named Jiang, was 59 years old when she first consulted Dr. Zhang on April 19, 1982. At the first visit she had had progressive dysphagia and dyspnea for half a year, with bloody pleural effusion for three months. Western examination diagnosed a right lower mediastinal tumor of undetermined nature, with right pleural effusion; three pleural-fluid examinations were bloody, but no cancer cells could be found in the fluid. The patient appeared critically ill: emaciated and weak, drooping eyelids, obstructed swallowing, poor appetite and shortness of breath, palpitations and fright, faint breath, right chest pain preventing her from lying on that side, dry bound stool (no bowel movement for three days), and scanty dark urine.
Dr. Zhang diagnosed the patient as having the TCM conditions of Ye-Ge (dysphagia) and Xuan-Yin (suspended fluid retention), and planned to treat by expelling phlegm and stasis, scattering nodules and promoting urination. The first-visit prescription was as follows: Gualou (Trichosanthes fruit) 15 g, Zexie (Alisma) 15 g, Zhuling (Polyporus) 12 g, Xiebai (Allium) 12 g, Sangbaipi (Morus root bark) 9 g, Fabanxia (prepared Pinellia) 9 g, Yujin (Curcuma) 9 g, Jiuxiangchong (Aspongopus) 6 g, Dibiechong (Eupolyphaga/Steleophaga) 5 g, Nanshashen (Glehnia/Adenophora) 30 g, Baihuasheshecao (Oldenlandia) 30 g, Hupo fen (Amber powder, taken infused) 3 g. Seven doses.
In addition, Hekui injection (intramuscular, 4 ml each time) was given, together with the patent medicines Liushen Wan and Zhongjiefeng tablets, orally.
After one week of medication, at the April 27 follow-up the patient reported that after taking the above formula the stool moved smoothly, and the chest oppression, cough and panting lessened, but dysphagia and fatigue and lack of strength remained.
Second-visit prescription: Zhixingzi (Impatiens seed) 12 g, Weilingxian (Clematis) 12 g, Shandougen (Sophora subprostrata root) 9 g, Wumei (Mume) 10 g, Jiangcan (Stiff Silkworm) 10 g, Gualou (Trichosanthes) 15 g, Maidong (Ophiopogon) 15 g, Kunbu (Ecklonia) 20 g, Haizao (Sargassum) 20 g, Xuanshen (Scrophularia) 20 g, Gancao (Licorice) 5 g.
In addition, the patent medicines Liushen Wan and Aitong Pian (note: Aitong Pian appears to be a preparation Dr. Zhang made himself; its formula was not published).
The patient took the above formula continuously for 24 days. At the third visit on May 25, the swallowing obstruction had markedly lessened; she could eat about 150 g of food per day, and the pleural effusion had decreased, but she coughed up a fair amount of white, sticky sputum, with drooping eyelids and fatigue. Tongge pale red with thin yellow greasy coating; pulse choppy.
Prescription: Lugen (Phragmites rhizome) 30 g, Maogen (Imperata rhizome) 30 g, Xingren (Apricot kernel) 30 g, Yiyiren (Coix seed) 30 g, Dongguaren (Winter melon seed) 30 g, Baihuasheshecao (Oldenlandia) 30 g, Xianhecao (Agrimonia) 30 g, Lvcao (Humulus) 30 g, Cheqiancao (Plantago) 30 g, Zexie (Alisma) 15 g, Fulin (Poria) 15 g, Maidong (Ophiopogon) 15 g.
In addition, the patent medicines Aitong Pian and Zhongjiefeng tablets.
The patient continued taking the formula until August 18; the fourth visit was on August 19. At the fourth visit her spirit had improved, swallowing was normal, appetite had increased, there was no chest or hypochondriac pain, and her eyelids were back to normal. A follow-up chest X-ray showed the pleural effusion had disappeared, and the tumor was the same size as before. Dr. Zhang considered that the patient’s righteous qi was gradually recovering and the Ye-Ge had been resolved; from then on, treatment should focus on the accumulation formed by congealed phlegm and stasis.
Fourth-visit prescription: Nanshashen (Glehnia/Adenophora) 30 g, Yiyiren (Coix seed) 30 g, Lugen (Phragmites rhizome) 30 g, Yuxingcao (Houttuynia) 30 g, Baihuasheshecao (Oldenlandia) 30 g, Gualoupi (Trichosanthes peel) 15 g, Danshen (Salvia) 15 g, Ezhu (Curcuma zedoaria) 15 g, Zhiqiao (Citrus aurantium) 12 g, Sharen (Amomum, ground and infused) 6 g, Chuanbeifen (Fritillaria cirrhosa powder, taken infused) 5 g.
Plus the patent medicines Houtoujun tablets, Shedan Chuanbei tablets, and Hekui injection.
The patient took the formula until October 14, 1982, by which point all clinical symptoms had disappeared. Her spirit was good; she ate 300–400 g of food daily and could do housework. The formula was then modified on the base prescription to consolidate the effect. Follow-up for two years showed no recurrence.
Imaging in this patient showed a mediastinal tumor and pleural effusion. Although no cancer cells were detected in the pleural fluid, her clinical presentation essentially allows a diagnosis of advanced mediastinal tumor (oncological patients with pleural or peritoneal effusion are classified as having advanced, metastasized disease). The patient was critically ill at presentation but had not undergone much invasive treatment. Dr. Zhang therefore, following TCM’s principle of treatment by pattern differentiation, diagnosed her as Ye-Ge and Xuan-Yin.
Patients with a mediastinal tumor do indeed develop Ye-Ge symptoms, so this pattern differentiation was reasonable. Western examination had already found pleural effusion, so differentiating it as Xuan-Yin was likewise reasonable. Ye-Ge and Xuan-Yin are both excess patterns, yet this patient also showed signs of great deficiency, making treatment difficult. But her deficiency of righteousness was caused by repletion of pathogen; treatment should therefore focus on expelling the pathogen. Dr. Zhang followed Zhang Zihe’s principle of “once the pathogen is expelled, the righteous will settle on its own,” prescribing mainly to attack the pathogen.
The patient had chest pain together with phlegm-fluid retention, so treatment should also consider treating it as chest impediment (xiongbi). At the first visit Dr. Zhang used Gualou Xiebai Banxia Tang, the TCM formula for chest impediment, as the base, adding water-promoting, swelling-dispersing herbs (Fulin, Zhuling, Zexie, Sangbaipi), blood-activating, pain-relieving herbs (Jiuxiangchong, Dibiechong, Yujin), plus heat-clearing, toxin-resolving, anti-cancer, mass-dispersing Baihuasheshecao; yin-nourishing, lung-moisturizing Nanshashen; and spirit-calming, sleep-aiding Hupo powder. This built a compound that activates blood and resolves stasis, dissipates phlegm and scatters nodules, promotes urination and disperses swelling, resolves toxin and fights cancer. He also used the anti-tumor Liushen Wan, Zhongjiefeng tablets and Hekui injection. Hekui injection is Hekui zhusheye, an injectable prepared from the Chinese herbs Taoren (Peach kernel) and Tiankui (Semiaquilegia). Its main actions are anti-inflammatory, dampness-draining and swelling-dispersing; it is a common adjunctive anti-tumor drug used by oncology physicians.
This prescription fully embodies the TCM spirit of treatment by pattern differentiation: the reasoning is clear and the medicinals address both root and branch. At the second visit, the symptoms from the pleural effusion had lessened, but the Ye-Ge symptoms had not; Dr. Zhang then heavily used Zhixingzi and Weilingxian, the two specific herbs for Ye-Ge, used Shandougen to clear heat, resolve toxin, fight cancer and disperse swelling, and used Jiangcan, Kunbu, Haizao and Gualou to soften hardness and scatter nodules, and Xuanshen to cool blood and disperse swelling.
It should be noted that the second-visit prescription already used an “eighteen incompatibilities” pairing (Haizao and Gancao are a herb pair among the TCM “eighteen incompatibilities”). Nowadays many doctors may not dare prescribe this way, and many pharmacies will not dispense it. Yet in some classical TCM external-surgery formulas, Haizao and Gancao are routinely used together — for example, Haizao Yuhu Tang in Chen Shigong’s Waike Zhengzong (Ming dynasty) uses both. The “eighteen incompatibilities” are not entirely reasonable, and one should not be rigid about them.
By the third visit, the Ye-Ge symptoms had clearly lessened, but she coughed up much phlegm. Dr. Zhang therefore adjusted the treatment direction, no longer using herbs for Ye-Ge and instead using herbs for cough with profuse phlegm. The third visit was based on Weijing Tang, adding herbs that dissipate phlegm, stop cough, promote urination and disperse swelling.
Through both the second and third visits, the anti-tumor patent medicines were continued. Treated along these lines, the patient’s clinical symptoms gradually lessened; by the fourth visit and afterward, the basic symptoms had disappeared. Treatment should not be changed too drastically, so from the fourth visit on, the doctor essentially kept the third-visit prescription, making minor adjustments according to the patient’s current condition.
This patient’s mediastinal tumor was not surgically removed; she had already developed pleural effusion and ocular muscle weakness, and was critically ill with a poor prognosis. That Dr. Zhang brought her to this state was no small achievement. Looking back over the whole treatment, it was actually not complicated: Dr. Zhang consistently combined pattern differentiation with disease differentiation. Based on the patient’s clinical symptoms, he used certain classical TCM formulas as bases and added or subtracted herbs in a targeted way to relieve symptoms. He then kept using anti-tumor medicines such as Liushen Wan and Zhongjiefeng tablets for continuous anti-tumor treatment. In the end the patient’s symptoms were relieved and the tumor was controlled, with no recurrence over two years.