Appreciating Zhao Yongchang's Treatment of Breast Nodules and Accessory-Breast Abscess

Professor Zhao Yongchang was born in 1920. He was Manchu, from a family that had practiced medicine for generations. Starting in 1940, he apprenticed under Duan Futing, the great TCM external-medicine master; he was a great TCM physician of the apprenticeship lineage. At the end of 1958 he was transferred to work at the Guanganmen Hospital of the China Academy of Chinese Medical Sciences, where he remained for a long time. He served as a member of the Expert Advisory Committee and of the Degree Evaluation Committee of the China Academy of TCM. He strongly advocated the integrated internal-external treatment principle in TCM external medicine and created the supplement-and-disperse method in TCM external surgery.

Old Zhao devoted his life to the clinical practice and research of TCM external medicine. Rooting himself in the yin-yang and zang-xiang doctrine of the Huangdi Neijing, he held that external diseases should be approached from the basic theory of yin-yang growth, decline, and balance, focusing on the dialectical unity among the broad natural environment, the body's small system, and the local lesion. Integrating supplementing and dispersing, he created a complete theoretical framework for treating yin-pattern carbuncles and swellings. Professor Zhao helped organize Doctor Duan Futing's book Zhongyi Waike Zhengzhi Zhiyan, a famous work in modern TCM external medicine.

This article introduces two cases treated by Old Zhao himself, from which we may grasp his approach to external disease with TCM.

Case 1: Treating rubella-like breast nodule (ru pi) by nourishing blood and soothing the liver, regulating qi and resolving phlegm

The patient, a 36-year-old woman surnamed Yang, first saw Old Zhao on December 21, 1991. She had had pain in the left breast for half a year. In January 1991 her own elder sister was diagnosed with breast cancer, which left her both depressed and tense; a month later she felt left-breast pain and sought no treatment. In early October of the same year, after noticing yellow fluid and a little milk discharging from the nipple, she went to hospital; taking ready-made medicines such as Rupixiao gave poor effect.

Palpation found scattered broad-bean-sized nodules palpable in the left breast, tender on touch. On light pressure, yellow-green fluid issued from the nipple, followed by white milk. The patient was irritable and impatient, with lower-back soreness and fatigue, abdominal fullness, a fine pulse, a dark tongue, and thin white coating. Old Zhao diagnosed ru pi, the pattern being blood deficiency with liver depression, and treated by nourishing blood and soothing the liver, regulating qi and resolving phlegm.

First-visit prescription: Chaihu (Bupleuri Radix) 10 g, Huangqin (Scutellariae Radix) 15 g, Baishao (Paeoniae Radix Alba) 10 g, Zaojiaoci (Gleditsiae Spina) 10 g, Xiangfu (Cyperi Rhizoma) 10 g, Danggui (Angelicae Sinensis Radix) 10 g, Sheng Shijueming (Haliotidis Concha) 30 g, Sheng Puhuang (Typhae Pollen, raw) 10 g. After 7 doses, the patient reported at follow-up that the pain was less; on the basis of the first prescription, Danshen (Salviae Miltiorrhizae Radix) and Sheng Muli (Ostrea Concha, raw) were added for continued use. On medication, her irritability gradually lessened and the nodules gradually shrank, later even disappearing completely. Yinyanghuo (Epimedii Herba) was then added and continued until January 1992 to consolidate; on recheck, all symptoms had completely resolved and the nodules were gone, so treatment stopped.

In this case, the patient's breast nodules were strongly related to her emotional swings. Breast cancer is indeed influenced by family genes; for example, a BRCA1 gene mutation on chromosome 17 usually raises the risk of breast and ovarian cancer in the women of that family. This case does not mention whether the patient's sister had a BRCA1 mutation, so we do not know whether such a mutation exists in their family.

On learning her sister had breast cancer, the patient inevitably developed cancer fear. This is a common problem among family members of cancer patients: while caring for a sick relative, most worry whether they themselves will get cancer. Anxiety, fear, and unease disrupt one's routines and adversely affect the body. This patient not only had emotional swings but also developed substantive organic lesions—nodules on the breast and nipple discharge.

So Old Zhao first approached this patient through regulating her emotions. His first prescription followed the logic of Sini San, modified. Chaihu and Xiangfu soothe the liver and regulate qi; Baishao softens the liver and stops pain; Huangqin clears heat and resolves toxin; Zaojiaoci (Gleditsiae Spina) drains pus and scatters nodules; Danggui and Puhuang activate and supplement blood; Shijueming softens hard masses and subdues liver hyperactivity. This combination aimed to soothe the liver and resolve depression, nourish blood and invigorate blood, regulate qi and resolve phlegm, and drain pus and scatter nodules, so the patient began to see some effect.

At the first follow-up, seeing the approach working, Old Zhao, for better effect, added Danshen to strengthen blood-activating, stasis-resolving power and added raw Muli to strengthen hard-mass-softening power; the patient's condition further improved. At the final visit he added Yinyanghuo (Epimedium), a TCM kidney-supplementing herb; modern pharmacology shows it regulates estrogen, and female breast nodules are often estrogen-related. Adding Epimedium could regulate the patient's endocrinology at the root and thereby control the nodules.

Old Zhao's medication was meticulous in reasoning and strict in method, so his effectiveness was only to be expected.

Case 2: Treating accessory-breast abscess by clearing heat and resolving toxin, activating blood and unblocking collaterals

The patient, a 28-year-old woman surnamed Yin, first saw Old Zhao on June 23, 1992. She had had pain in the left axilla for over ten days. Two weeks earlier, after squeezing the left axilla she felt stabbing pain, worse on touch. A week earlier she developed fever, 37.5°C; taking antibiotics gave poor effect, with temperature staying around 37.3°C. She was fatigued, with a rapid pulse, a normal tongue and thin white coating.

After pattern differentiation, Old Zhao considered the patient to have blood stasis obstructing collaterals with accumulation transforming to heat, and treated by clearing heat and resolving toxin, and activating blood and unblocking collaterals.

First-visit prescription: Jinyinhua (Lonicerae Flos), Zihuadiding (Violæ Herba), and Rendongteng (Lonicerae Caulis) each 20 g; Pugongying (Taraxaci Herba) and Gualou (Trichosanthis Fructus) each 15 g; Jubaye (Citri Folium) 12 g; Zaojiaoci (Gleditsiae Spina), Qingpi (Citri Reticulatae Pericarpium Viride), and Chenpi (Citri Reticulatae Pericarpium) each 10 g; Muxiang (Aucklandiae Radix) 6 g. Seven doses, decocted in water.

After seven doses the fever was gone. Following the principle of not changing an effective formula, the patient took another seven doses before follow-up. At the next visit the axillary lymph nodes had resolved and all symptoms had lessened, though pain remained. On the basis of the above, Chenpi was removed, Chaihu (Bupleuri Radix) 10 g added, and seven more doses taken; pain lessened and the previously red, swollen skin returned to normal. Danshen (Salviae Miltiorrhizae Radix) 12 g was added and seven more doses taken; pain further lessened. At another visit, Jinyinhua was removed, Zaojiaoci increased to 12 g, and seven more doses taken to consolidate.

In this case the patient had developed a nodule in the accessory-breast system, with the obvious redness, swelling, heat, and pain of a typical "yang abscess." In treating such patients, Old Zhao followed the principle that yang abscesses should be treated by combining heat-clearing-toxin-resolving with blood-activating-stasis-resolving, following the prescribing logic of Wuwei Xiaodu Yin, modified.

Jinyinhua, Diding, Rendongteng, and Pugongying are the main components of Wuwei Xiaodu Yin. Wuwei Xiaodu Yin is a famous TCM external-medicine formula, composed of Jinyinhua, Diding, Pugongying, Yejuhua (Chrysanthemi Indici Flos), and Zibeitiankui (Semiquilegiae Herba), with the actions of clearing heat and resolving toxin, and dispersing swelling and scrofula; it is the representative TCM formula for "yang abscesses." Old Zhao's formula, on the basis of Wuwei Xiaodu Yin, added Gualou, Jubaye, Zaojiaoci, and other herbs with specific effects on breast nodules, plus Qingpi, Chenpi, and Muxiang to regulate qi and scatter nodules. Such an all-around prescription befits a master.

After the patient took the medicine, her temperature returned to normal, showing the internal heat-toxin was lessening, but pain remained; Old Zhao then added Chaihu to soothe the liver and stop pain, later added Danshen to cool and invigorate blood, and increased the dose of Zaojiaoci, the nodule-dispersing, swelling-relieving herb. These were all targeted adjustments based on the patient's changing condition. After several such adjustments the patient's condition greatly improved. The process of adjustment was orderly and measured, reflecting the deep fundamentals of an old-generation, apprenticeship-trained physician.

Studying medical cases can, like following a master, teach the essence of the teacher's diagnostic and therapeutic thinking. That is why I personally strongly recommend that everyone study medical cases.