Clinical Experience in Treating Paralysis Caused by Brain Tumors and Hydrocephalus with Zhenwu Tang (True Warrior Decoction)

Zhenwu Tang is a classic famous formula from the Shanghan Lun (Treatise on Cold Damage). Its original name was Xuanwu Tang. When Lin Yi and others of the Northern Song proofread the Shanghan Lun, they renamed it Zhenwu Tang to avoid the naming taboo on the ancestor of the Song imperial house.

Because Lin Yi's proofread edition of the Shanghan Lun was so influential, later generations have all called it Zhenwu Tang. But in the Japanese Kampo medical community, many physicians still call it by its original name, Xuanwu Tang. Today, of the Zhenwu Tang granules produced by Japanese Kampo pharmaceutical companies, some are called Zhenwu Tang and some Xuanwu Tang.

Xuanwu (the Black Warrior) is one of the Four Symbols of the heavens in ancient Chinese mythology; it is the god of the North and governs water. So Zhenwu Tang is in fact a formula that warms yang and promotes water metabolism, which is why it is named after Xuanwu.

Zhenwu Tang comprises five herbs. The Shanghan Lun records its composition as: one piece of aconite (prepared, broken into 8 pieces), two liang of Atractylodes macrocephala (Baizhu), three liang of Poria (Fuling), three liang of white peony (Baishao), and three liang of fresh ginger (Shengjiang). In clinical practice I commonly use 10g aconite, 10g Baizhu, 10g Fuling, 6g Baishao, and 3-7 slices of Shengjiang.

Shanghan Lun, Article 82: "In taiyang disease, when sweating is promoted and the sweating does not resolve the condition, the person still has fever, palpitations below the heart, dizziness, twitching of the body, and a shaking desire to press the ground—Zhenwu Tang governs."

Shanghan Lun, Article 316: "In shaoyin disease, when it has not resolved after two or three days, and by the fourth or fifth day there is abdominal pain, difficult urination, heavy painful limbs, and spontaneous diarrhea, this indicates presence of water qi. If the person coughs, or has easy urination, or diarrhea, or vomiting—Zhenwu Tang governs."

These two articles are the earliest descriptions of the indications for Zhenwu Tang.

According to Article 82, when a patient has palpitations or uneasy throbbing in the epigastrium, dizziness and vertigo, involuntary twitching in some part of the body, weak trembling legs, and a frequent tendency to fall, Zhenwu Tang should be used.

According to Article 316, when shaoyin disease drags on, with abdominal pain, urination either difficult or excessive, sticky loose stools or frequent bowel movements, and heavy painful limbs, this is an indication of water qi; if the patient coughs, or has frequent urination, or loose/diarrheal stools, or vomiting, Zhenwu Tang should be used.

In fact, all of these syndromes point to one root cause: the patient has yang deficiency with water flooding.

The Japanese Kampo physician Dōmoto Shinkyū summarized the causes of human disease as "the stagnation of the three poisons—food, water, and blood" (see the chapter "On How Infectious Disease Cannot Be Established Without Presupposing Autointoxication" in his Kōkan Igaku). This view, though not entirely correct, has considerable validity.

In patients with yang deficiency, yang fails to control yin, and water floods as a pathogen. In Dōmoto Shinkyū's terms, the water poison stagnates in the body; if the water poison is not removed, a hundred diseases arise.

When water stagnates, a whole series of symptoms appear: "It may surge upward to the heart and cause palpitations, shoot upward to the lungs and cause panting, attack upward to the stomach and cause vomiting, assail the clear orifices and cause dizziness, overflow outward to the skin and cause swelling, or accumulate in the bladder and cause difficult urination." (see the "Zhenwu Tang" chapter in Shanghan Mingyi Yan'an Jingxuan, edited by Chen Ming and Zhang Yinsheng).

Stagnant water in the body produces not only these symptoms but many more. For example, water accumulating in the intestines causes loose or diarrheal stools; water stagnating in the meridians produces neuralgic pain such as sciatica; water stagnating in the joints produces symptoms such as rheumatoid arthritis; and overflowing water-cold can even lead to depression.

Therefore, for any disease caused by water stagnation, as long as the pattern is differentiated as yang deficiency with water flooding, Zhenwu Tang can be used with good effect. Dr. Chen Ming has collected many verified cases of Zhenwu Tang treating various difficult and complicated diseases; readers can consult the Shanghan Mingyi Yan'an Jingxuan he edited and will find it rewarding.

So how do we determine that a patient has yang deficiency with water flooding?

First, yang deficiency produces symptoms such as aversion to cold and cold limbs. The pulse is generally a deficient pulse. Specifically, the pulse corresponding to Zhenwu Tang is often deep and minute (chen-wei), deep and fine (chen-xi), deep and weak (chen-ruo), or wiry and fine (xian-xi).

Per Professor Hu Xishu's explanation, a floating pulse also indicates stagnation of the water poison, but a floating pulse means the water poison is stagnating at the body's surface, so it should be treated with the sweating method.

A deep pulse, on the other hand, means the water poison is stagnating in the body's depths. A deep and deficient, or wiry and deficient, pulse arises because yang qi is debilitated and yang cannot overcome yin, so this yin substance—water—floods and runs rampant in the body.

At this point, only the method of supporting yang can treat it. The ancients likened this therapeutic principle to "as soon as the sun rises, the haze vanishes at once"; that is, after taking yang-supporting herbs, the body's yang qi becomes sufficient, just as accumulated water on the ground automatically evaporates when the sun comes out.

Do not underestimate TCM pulse diagnosis. Nowadays many students of TCM cannot read the pulse, so their prescriptions do not match the pattern and patients get no effect. If the formula matches the pattern, generally the patient will feel something within three doses.

Besides pulse diagnosis, tongue diagnosis is also needed. What, then, is the tongue presentation of yang deficiency with water flooding? The single greatest feature is a clearly wet, slippery tongue (huashe) or an enlarged tongue with teeth marks (chihenshe).

Some patients have an enlarged tongue with teeth marks along the edges; some have a tongue that is perpetually wet and drippy—ordinary people's tongues are not as moist as theirs. These are all signs of a wet, slippery tongue, indicating heavy dampness.

Beyond pulse and tongue diagnosis, one must further collect other signs of the patient, which requires talking with the patient to gain a deeper understanding.

Generally, patients with yang deficiency and water flooding have either frequent or difficult urination, but the urine is mostly clear and transparent, not dark yellow. Dark yellow urine usually indicates internal heat, and yang-tonifying herbs must not be used recklessly. The stools may be unformed (so-called loose stools) or diarrheal.

The body is also prone to pain, the limbs are heavy and weak, the head feels tight as if wrapped in cloth, and the muscles are not relaxed. Or, in some parts of the body, the muscles twitch involuntarily—"body twitching," as it were!

These are the main signs of yang deficiency with water flooding. In fact, once you grasp these main signs, you need not pay much attention to the various accompanying symptoms the patient describes; directly resolving the main signs makes the accompanying symptoms resolve on their own without treatment.

For example, I recently treated a breast cancer patient with Zhenwu Tang. She complained of insomnia, which is not among the indications of Zhenwu Tang, but her main signs pointed to the pattern of yang deficiency with water flooding. So I ignored whether she had insomnia or not and directly used Zhenwu Tang. As a result, after only one day of medication, the insomnia—an accompanying symptom—disappeared.

Here I must say a word more. Many beginners in TCM love to add symptom-targeting herbs to classic formulas historically known to be effective. This is not forbidden, but sometimes it is unnecessary. Just prescribe a simple formula first, let the patient take it, and observe; most of the time the accompanying symptoms resolve on their own.

This is because some TCM formulas, in treating certain diseases, originally cover a very wide range of symptoms, but earlier physicians only recorded a few simple main signs. So sometimes we must learn to grasp the principal contradiction when using a formula—just resolve the principal contradiction.

The above actually explains the principle behind using Zhenwu Tang quite thoroughly.

Now let me explain why I would use Zhenwu Tang to treat paralysis caused by brain tumors or hydrocephalus. It is because some brain tumor or hydrocephalus patients present with symptoms that are precisely the indications for Zhenwu Tang.

They have weak, limp legs. In a recent patient I treated who had a spinal chordoma compressing cranial nerves together with hydrocephalus, I first used my modified Huangqi Fangji Tang to drain water, to no effect. I then used Sanren Tang (because it was summer), also to no effect.

After two months of treatment, apart from my own Zhenfeng Sanjie Wan, which I had developed to suppress brain tumors and which improved some of his cerebral symptoms, there was no effect on his paralysis at all.

This patient was a relative of another patient I had treated; that other patient, after treatment for a different tumor, was in excellent condition with the tumor ideally controlled.

I tried several times and saw no effect on this patient's paralysis. Feeling that I could no longer delay him, I intended for him to seek a more skilled doctor. But because of the therapeutic effect on their relative, the patient's family refused to change doctors.

A few days before the Mid-Autumn Festival, he came to me again for a follow-up. After a detailed inspection, listening-smelling, inquiry, and pulse-taking diagnosis, I thought it over and felt that Zhenwu Tang should be used.

So I prescribed modified Zhenwu Tang: 10g aconite, 6g Baizhu, 10g Fuling, 10g Polyporus (Zhuling), 10g Baishao, 30g fried malt (Chao Maiya), 30g fried rice sprout (Chao Guya), and 7 slices of Shengjiang. Plus the anti-tumor Chinese patent medicine he had been taking.

Within less than a week of taking the medicine, the patient could rise from his wheelchair and walk several dozen meters. Though the medication was simple, the effect was very obvious.

It is clear that, even for such severely ill patients, as long as the right medicine is used, a prompt effect can still be achieved, effectively improving the patient's quality of life and prolonging survival.

In this patient, I initially took a detour.

Because he had hydrocephalus, I had previously treated another advanced-stage tumor patient whose paralysis was caused by hydrocephalus, using modified Huangqi Fangji Tang with good effect. That patient, in less than a week, rose from the wheelchair, and within about half a month could set the wheelchair aside and walk on his own.

I committed the error of empiricism, applying Huangqi Fangji Tang to this patient as well without careful TCM pattern differentiation (though pattern differentiation and treatment is indeed a highly demanding task). The result was no efficacy. Later I changed course, differentiated the pattern accurately, and the effect was immediate.

Had this patient not had a relative treated successfully under my care, I would have treated him for about two months with no improvement in his paralysis, and he would probably have changed doctors long ago. He would never have given me the chance to discover my own error. So sometimes patients speak of a "medical affinity"—treating illness truly requires a certain karmic connection.

The herbs in Zhenwu Tang can be described as very simple. Of the five, aconite warms and tonifies kidney yang, Baizhu warms and tonifies spleen yang, Fuling leaches out dampness and promotes urination, Baishao nourishes yin and promotes water metabolism, and Shengjiang is both a warming herb and a very good water-promoting herb.

In my hometown there was an old TCM doctor who, using only large amounts of Shengjiang and Dazao (jujube) and nothing else, cured a relative of his of ascites due to liver disease. This is a therapeutic effect I personally verified—not idle talk. It shows that Shengjiang has an excellent water-promoting effect, but such an effect requires pattern-based prescribing.

These five herbs can all be said to be water-promoting; four belong to the warming-tonifying category of hot herbs, and only Baishao both promotes water metabolism and nourishes yin.

So why does this yang-supporting formula, Zhenwu Tang, need Baishao?

I had originally planned to write a separate article on this question, but since I have reached this point, I might as well say a few words about the importance of the TCM principle of mutually opposing yet complementary formula composition.

Recently a TCM colleague turned to me for help. Her mother had cirrhosis with ascites, and she herself had treated her mother for about four years using the basic approach of soothing the liver and resolving depression, softening hardness and dispersing nodules, and activating blood and promoting water metabolism. But because the treatment went on too long, her mother suffered massive gastric hemorrhage and nearly lost her life.

I looked at her formula: it used large amounts of blood-activating herbs without any hemostatic herbs—that was the problem. In fact, many TCM formulas use herbs with opposing properties.

When using yang-tonifying herbs, one must add some yin-nourishing herbs. Zhang Jingyue of the Ming dynasty called this "seeking yang within yin." When using yin-nourishing herbs, one must add some yang-tonifying herbs; Zhang Jingyue called this "seeking yin within yang."

Of course, Zhang Jingyue's explanation is also fine; it is just a bit mysterious and hard to understand.

In fact, if too many yang-tonifying herbs are used without adding yin-nourishing ones, the patient easily over-tonifies yang and damages yin fluids. If too many yin-nourishing herbs are used, the patient easily over-nourishes yin and damages spleen yang. The ancients said that yin-nourishing herbs "obstruct the diaphragm"; when too many cold-cool herbs are taken, the patient's appetite suffers.

So one must use the principle of opposing-yet-complementary medication. When treating with yang-tonifying herbs, add some yin-nourishing herbs to counteract the side effects of the yang tonics, so as to avoid over-tonifying yang and a yang-exuberant reaction. When treating with yin-nourishing herbs, add some yang-tonifying herbs so as not to affect the appetite or damage the upright qi.

Likewise, learn to draw inferences from one instance. When using blood-activating herbs, add some hemostatic herbs, so as to activate blood without injuring it. When using hemostatic herbs, add some blood-activating herbs, so as to stop bleeding without leaving stasis.

I once had a reader who was also a TCM physician. At first, seeing that the formulas in my case records were very complex, with many opposing herbs used in the same formula, he despised them, thinking I was prescribing recklessly.

Then once, a patient he was treating suffered massive bleeding; he panicked and had to turn to me for help.

I pointed out the problem in his formula, had him use Bletilla (Baiji) and ginseng to stop the patient's bleeding, and told him that whenever he used his original formula again, he must add hemostatic herbs. I helped him resolve this medical mishap, and afterward he was quite convinced.

Many beginners in TCM read the case records of experienced clinicians but cannot understand them; with no teacher to guide them and unable to think or draw inferences, they never get started.

I hope that, when studying TCM and reading case records, everyone will think more and be able to draw inferences; otherwise, TCM truly cannot be learned well.

I also hope that, when choosing TCM treatment, patients will not blindly apply the habitual thinking of "this formula treats that disease" and use medicine recklessly. Even an experienced TCM physician struggles to prescribe the right formula; how much less should those of you with no experience at all use medicine recklessly?

Of course, I myself am still on the path of growth, and the above are only my own shallow observations, unfit for the hall of elegance; I welcome corrections from learned experts.

Treating paralysis caused by brain tumors and hydrocephalus is not easy. To truly resolve the patient's problem, one must combine pattern differentiation with disease differentiation; and where the opportunity for integrated Chinese-Western medicine exists, it should be used, as the effect will be more ideal.

If a patient has lost the opportunity for Western treatment, then use Chinese medicine alone as much as possible to resolve the patient's problem. The patient in this article had failed Western treatment, so he could only be treated with pure Chinese medicine.

As for that nonsense from Western medicine about how Chinese medicine cannot cross the blood-brain barrier—do not believe it. As long as pattern differentiation and disease differentiation are combined, the patient's problem can still possibly be resolved.

Of course, if a patient has read too much modern literature and firmly believes that Chinese medicine cannot cross the blood-brain barrier, we should shut our mouths; such personal prejudice cannot be changed.

Speaking more is not only unhelpful but easily provokes medical disputes. Those of us who study TCM should not waste time on this question; let us just do our research and clinical work well.

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