Abdominal Masses

CHAPTER 60 Abdominal Masses



AETIOLOGY 794

PATHOLOGY 794

IDENTIFICATION OF PATTERNS AND TREATMENT 794

QI MASSES 795
Liver-Qi stagnation 795

Retention of food and Phlegm 796

BLOOD MASSES 798
Stagnation of Qi and Blood 798

Stasis of Blood knotted in the Interior 799

Deficiency of Upright Qi and stasis of Blood 802

PROGNOSIS AND PREVENTION 803

WESTERN VIEW 804

APPENDIX I: OVARIAN CYSTS 805
Aetiology and pathology 805

Herbal treatment 806

APPENDIX II: CERVICAL DYSPLASIA 807
Treatment 809

Abdominal masses are called Ji Ju (image). Ji indicates actual abdominal masses which are immovable; if there is an associated pain, its location is fixed. These masses are due to stasis of Blood. I shall call them ‘Blood masses’. Ju indicates abdominal masses which come and go, do not have a fixed location and are movable; if there is an associated pain, it too comes and goes and changes location. Such masses are due to stagnation of Qi. I shall call them ‘Qi masses’. Actual abdominal lumps therefore pertain to the category of abdominal masses and specifically Ji masses, i.e. Blood masses.


Another name for abdominal masses was Zheng Jia (image), Zheng being equivalent to Ji, i.e. actual, fixed masses, and Jia to Ju, i.e. non-substantial masses from stagnation of Qi. Zheng Jia is normally used in referring to abdominal masses that generally occur only in women; but they do occur in men as well, though rarely. Chapter 60 of the Simple Questions says: “Diseases of the Directing Vessel … in women are masses below the waist.”1 In this context, the Simple Questions uses the term Jia-Ju, i.e. non-substantial masses from Qi stagnation.


The term Ji Ju appears in the Classic of Difficulties which clearly distinguishes the two types:



Ji masses pertain to Yin and Ju masses to Yang … When Qi accumulates it gives rise to Ji masses, when it gathers it gives rise to Ju masses. Ji masses arise from the Yin organs and Ju masses from the Fu organs. Ji masses have a fixed location and pain, and have boundaries above and below, and edges to the right and left [i.e. they have clearly defined borders]. Ju masses seem to start from nowhere, without a boundary above and below and with a moving pain.2


The Essential Prescriptions of the Golden Cabinet by Zhang Zhong Jing says:



Ji masses arise from the Yin organs and they cannot be moved; Ju masses arise from the Yang organs, they come and go, the pain has no fixed location, and they are easier to treat.3


The General Treatise on the Aetiology and Symptoms of Diseases (AD 610) says:



Abdominal masses are due to cold and heat not being regulated [i.e. exposure to extremes of weather], irregular diet and stagnation of the Qi of the Yin organs. If they do not move they are called Zheng; if they are movable they are called Jia. ‘Jia’ implies the meaning of ‘false’: this is because these masses can come and go and are not actual masses.4


Since the time of the Tang dynasty, eight types of women’s abdominal masses have been described, i.e. yellow, green, dry, blood, fat, fox, snake and turtle mass.



Aetiology




Emotional strain


Emotional strain is the most common cause of the formation of abdominal masses. Anger, especially when repressed, frustration, resentment, hatred, worry and guilt can all lead to stagnation of Liver-Qi and, in the long run, to stasis of Liver-Blood. The Liver channel plays an important role in the movement of Qi in the lower abdomen and, in women, Liver-Blood plays a paramount role in the circulation of Blood in this area.



Irregular diet


Diet is another important aetiological factor in the formation of abdominal masses. Irregular eating or the excessive consumption of cold and raw foods may lead to the formation of Cold in the lower abdomen. Cold contracts and naturally interferes with the circulation of Qi and, especially, Blood; it may lead to stasis of Blood.


Excessive consumption of greasy foods, on the other hand, impairs the Spleen and may lead to the formation of Dampness and Phlegm, which can settle in the lower abdomen and bring about abdominal masses. There is also a close interaction between Phlegm and stasis of Blood so that one may lead to or aggravate the other.



External pathogenic factors


External pathogenic factors are less important in the aetiology of abdominal masses. The most important pathogenic factor is external Cold which can invade the lower abdomen and impair the circulation of Blood eventually leading to stasis of Blood. Chapter 66 of the Spiritual Axis says: “Ji masses are due to Cold.”5


External Dampness may invade the channels of the legs and then creep up them to settle in the lower abdomen where, in the long run, it transforms into Phlegm and may give rise to abdominal masses.



Pathology


As for pathology, abdominal masses are always characterized by either stagnation of Qi or stasis of Blood, the former being non-substantial and the latter substantial masses. In addition to stagnation, there may also be Phlegm. However, in all cases of abdominal masses there is always an underlying deficiency of Qi. Deficient Qi fails to transport and transform and, leading to stagnation of Qi and Blood, it allows masses to form.


Masses from stagnation of Qi come and go, are movable on palpation and change location. If there is pain, the pain has no fixed location and is accompanied by a pronounced feeling of distension.


Masses from stasis of Blood are fixed in location, they are not movable on palpation and feel quite hard. If there is pain, it is fixed and stabbing in character.


Masses from Phlegm feel soft on palpation and have a fixed location. There is usually no pain.



Identification of patterns and treatment


The treatment of abdominal masses is always based on moving Qi and Blood. However, there are other factors to take into account depending on the stage of the disease. In the beginning stages of the condition, the pathogenic factor (stagnation of Qi or stasis of Blood) is relatively weak and the body’s Qi relatively strong. In the middle stages, the body’s Qi is weakening and the pathogenic factor becoming more prominent. In the late stages, the pathogenic factor is very prominent and the masses very developed while the body’s Qi is very weak.


Thus, irrespective of the pathogenic factor involved, the principle of treatment must be guided by the stage of the condition:


• In the beginning stages, primarily resolve the pathogenic factor, i.e. move Qi, invigorate Blood and resolve Phlegm.

• In the middle stages, resolve the pathogenic factor and tonify the body’s Qi simultaneously.

• In the late stages, primarily tonify the body’s Qi and secondarily resolve the pathogenic factor.

Also, when moving Qi in Qi masses, the treatment principle is to move Qi primarily and invigorate Blood secondarily. In Blood masses, the treatment principle is to invigorate Blood, eliminate stasis, ‘break’ Blood primarily and move Qi secondarily. Thus, the formulae given below are only a guideline. The approach adopted should be chosen according to the pattern of the disease, but the formulae must be modified in every case according to its stage.


Furthermore, all prescriptions indicated below should be modified with the addition of ‘softening’ herbs, i.e. herbs which soften masses: this is particularly necessary for masses from stasis of Blood or Phlegm. Softening herbs are:


• Yi Yi Ren Semen Coicis

• Zhe Bei Mu Bulbus Fritillariae thunbergii

• Hai Zao Sargassum

• Kun Bu Thallus Eckloniae

• Chuan Shan Jia Squama Manitis

• Xia Ku Cao Spica Prunellae

• Gui Ban Plastrum Testudinis

• Mu Li Concha Ostreae

• Jiang Can Bombyx batryticatus

• Bie Jia Carapax Trionycis

• Wa Leng Zi Concha Arcae

• Hai Dai Thallus Laminariae.

As for the relative application of acupuncture and herbal medicine, especially for Blood masses, the herbal treatment is primary in relation to acupuncture.


The patterns discussed are:







Qi masses


• Liver-Qi stagnation.

• Retention of food and Phlegm.


Blood masses


• Stagnation of Qi and Blood.

• Stasis of Blood knotted in the Interior.

• Deficiency of Upright Qi and stasis of Blood.


Qi masses



Liver-Qi stagnation



Clinical manifestations


Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry.



Treatment principle


Pacify the Liver, eliminate stagnation, move Qi and dissolve masses.



Acupuncture


G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method.




Explanation


– G.B.-34 and Ren-6, in combination, move Liver-Qi in the lower abdomen.

– LIV-3 moves Liver-Qi.

– P-6 indirectly moves Liver-Qi and calms the Mind.

– T.B.-6 moves Liver-Qi.

– SP-6 moves Qi and soothes the Liver. Specifically, it treats the lower abdomen.

– LU-7 and KI-6 are used in women to open the Directing Vessel and move Qi in the lower abdomen. The Directing Vessel is specific for abdominal masses.

– KI-14 moves Qi and Blood in the lower abdomen.

– Ren-6 moves Qi in the lower abdomen.


Herbal treatment



a Prescription


– XIAO YAO SAN

– Free and Easy Wanderer Powder


Explanation

This formula, which has already been explained, moves Liver-Qi in the lower abdomen.



Modifications


• In order to enhance the formula’s moving-Qi effect, add Xiang Fu Rhizoma Cyperi and Mu Xiang Radix Aucklandiae.

• If the stagnation and masses are very pronounced, add Yan Hu Suo Rhizoma Corydalis and Yu Jin Radix Curcumae.

• In an old person, add Dang Shen Radix Codonopsis or Ren Shen Radix Ginseng.

• If, in addition to stagnation of Qi, there is some Dampness and Phlegm (a very common situation), increase the dosage of Fu Ling, reduce that of Dang Gui and add Sha Ren Fructus Amomi, Cang Zhu Rhizoma Atractylodis and Huang Bo Cortex Phellodendri.


b Prescription


– XIANG LENG WAN

– Aucklandia-Sparganium Pill


Explanation


– Mu Xiang, Zhi Ke, Chuan Lian Zi and Qing Pi move Qi and eliminate stagnation.

– Ding Xiang and Xiao Hui Xiang warm the channels and scatter Cold in the abdomen.

– San Leng and E Zhu invigorate Blood, eliminate stasis and ‘break’ Blood.

The present formula differs from the previous one in three respects: it is much stronger in its action and better at dissolving masses, it invigorates Blood and it scatters Cold. It is therefore especially indicated when Qi stagnation is associated with Cold and the tongue is Pale and the pulse is Tight.



Modifications


• If the periods are late and scanty, add Dang Gui Radix Angelicae sinensis and Chuan Xiong Rhizoma Chuanxiong.

• If there is lower abdominal pain and a feeling of masses, remove Ding Xiang and add Li Zhi He Semen Litchi.

• If the abdominal pain is accompanied by a white vaginal discharge, add Pu Gong Ying Herba Taraxaci.


Women’s Treasure remedy


– FREEING THE MOON

This remedy pacifies the Liver, moves Qi, eliminates stagnation, tonifies Spleen-Qi, nourishes Liver-Blood and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with slightly Pale sides.



Summary



Liver-Qi stagnation


Clinical manifestations


Movable abdominal masses which come and go, abdominal distension and pain which come and go with the masses, a feeling of discomfort in the hypochondrium, depression, moodiness, irritability, alternation of constipation and diarrhoea. Tongue: the body colour may be normal or slightly Red on the sides. Pulse: Wiry.



Treatment principle


Pacify the Liver, eliminate stagnation, move Qi and dissolve masses.



Acupuncture


G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-14 Siman, Ren-6 Qihai. Reducing or even method.



Herbal treatment



Prescriptions



• XIAO YAO SAN Free and Easy Wanderer Powder

• XIANG LENG WAN Aucklandia-Sparganium Pill


Women’s Treasure remedy



• FREEING THE MOON


Retention of food and Phlegm



Clinical manifestations


Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery.



Treatment principle


Resolve food retention, regulate the bowels, move Qi and resolve Phlegm.



Acupuncture


Ren-12 Zhongwan, BL-20 Pishu, Ren-10 Xiawan, Ren-6 Qihai, L.I.-4 Hegu, ST-40 Fenglong, ST-36 Zusanli, BL-21 Weishu, ST-34 Liangqiu, SP-6 Sanyinjiao. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced.




Explanation


– Ren-12 and BL-20 tonify the Spleen to resolve Phlegm and promote transformation of food.

– Ren-10 promotes the descending of Stomach-Qi.

– Ren-6 moves Qi in the lower abdomen.

– L.I.-4 regulates the ascending and descending of Qi in the Stomach.

– ST-40 resolves Phlegm and promotes the descending of Stomach-Qi.

– ST-36 promotes the descending of Stomach-Qi and relieves constipation. If there is diarrhoea, replace this with ST-37 Shangjuxu.

– BL-21 and ST-34, Back-Transporting and Accumulation points respectively, promote the descending of Stomach-Qi.

– SP-6 resolves Dampness and moves Qi in the lower abdomen.


Herbal treatment



a Prescription


– LIU MO TANG

– Six Ground-Herbs Decoction


Explanation

This formula moves Qi and resolves food retention in the lower abdomen. It is particularly used if there is constipation.


– Mu Xiang, Wu Yao and Chen Xiang regulate Qi, eliminate stagnation and make Qi descend.

– Da Huang, Bing Lang and Zhi Shi move downwards and make Qi descend.


Modifications


• If there is diarrhoea, remove Da Huang and add Bai Zhu Rhizoma Atractylodis macrocephalae and Sha Ren Fructus Amomi.

• To enhance the Phlegm-resolving effect of this formula, add Ban Xia Rhizoma Pinelliae preparatum, Fu Ling Poria, Chen Pi Pericarpium Citri reticulatae and Zhe Bei Mu Bulbus Fritillariae thunbergii.

• If the retention of food is pronounced, add Ping Wei San Balancing the Stomach Powder plus Shan Zha Fructus Crataegi and Shen Qu Massa medicata fermentata.

• If there is deficiency of Qi (which is always present in chronic conditions), use Xiang Sha Liu Jun Zi Tang Aucklandia-Amomum Six Gentlemen Decoction, some herbs to move Qi in the lower abdomen, such as Xiang Fu Rhizoma Cyperi, and some to resolve Phlegm and lumps, such as Zhe Bei Mu Bulbus Fritillariae thunbergii.


b Prescription


– CANG FU DAO TAN WAN Variation

– Atractylodes-Cyperus Conducting Phlegm Pill Variation


Explanation


– Fu Ling, Chen Pi, Ban Xia and Dan Nan Xing resolve Dampness and Phlegm. Ban Xia was added to the original prescription.

– Xiang Fu and Zhi Ke move Qi and eliminate stagnation which will help to resolve Phlegm.

– Shen Qu and Sheng Jiang promote digestion and dissolve food accumulation, which will help to resolve Phlegm.

– Gan Cao harmonizes.


c Prescription


– KAI YU ZHENG YUAN SAN

– Opening Stagnation Upright Original [Qi] Powder


Explanation


– Bai Zhu tonifies Qi and dries Dampness.

– Chen Pi, Fu Ling and Sha Ren resolve Dampness.

– Qing Pi and Xiang Fu move Qi and eliminate stagnation.

– Shan Zha, Shen Qu and Mai Ya dissolve food accumulation and help to resolve Phlegm.

– Hai Fen and Jie Geng resolve Phlegm and soften and dissolve masses. If Hai Fen is unavailable, it can be replaced with Mu Li Concha Ostreae.

– Yan Hu Suo moves Qi and invigorates Blood.


Summary



Retention of food and Phlegm



Clinical manifestations


Soft abdominal masses, which may be strip-like in shape, abdominal distension, constipation or diarrhoea, poor appetite, nausea and a feeling of fullness. Tongue: Swollen, with a sticky coating which is thicker on the root. Pulse: Slippery.



Treatment principle


Resolve food retention, regulate the bowels, move Qi and resolve Phlegm.



Acupuncture


Ren-12 Zhongwan, BL-20 Pishu, Ren-10 Xiawan, Ren-6 Qihai, L.I.-4 Hegu, ST-40 Fenglong, ST-36 Zusanli, BL-21 Weishu, ST-34 Liangqiu, SP-6 Sanyinjiao. Reducing or even method, except on Ren-12 and BL-20 which should be reinforced.



Herbal treatment



Prescriptions



• LIU MO TANG Six Ground-Herbs Decoction

• CANG FU DAO TAN WAN Variation Atractylodes-Cyperus Conducting Phlegm Pill Variation

• KAI YU ZHENG YUAN SAN Opening Stagnation Upright Original [Qi] Powder


Blood masses



Stagnation of Qi and Blood



Clinical manifestations


Hard and immovable abdominal masses, abdominal distension and pain, late periods. Tongue: Purple. Pulse: Wiry.



Treatment principle


Move Qi, invigorate Blood, remove obstructions from the Connecting channels and dissolve masses.



Acupuncture


G.B.-34 Yanglingquan, Ren-6 Qihai, LIV-3 Taichong, T.B.-6 Zhigou, P-6 Neiguan, SP-6 Sanyinjiao, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), SP-10 Xuehai, BL-17 Geshu. Reducing or even method.




Explanation


– G.B.-34 and Ren-6 in combination, move Liver-Qi in the lower abdomen.

– LIV-3 moves Liver-Qi and Liver-Blood.

– P-6 indirectly moves Liver-Qi and calms the Mind.

– T.B.-6 moves Liver-Qi.

– SP-6 moves Blood and soothes the Liver. Specifically, it treats the lower abdomen.

– LU-7 and KI-6 are used in women to open the Directing Vessel and move Qi in the lower abdomen. The Directing Vessel is specific for abdominal masses.

– SP-10 and BL-17 invigorate Blood.


Herbal treatment



Prescription


– JIN LING ZI SAN and SHI XIAO SAN

– Toosendan Powder and Breaking into a Smile Powder


Explanation

The first formula (composed of the first two herbs) moves Liver-Qi and Liver-Blood and the second one invigorates Blood and stops pain in the lower abdomen.



b Prescription


– DA QI QI TANG

– Big Seven Qi Decoction


Explanation

This formula is selected if the stagnation of Qi and Blood in the lower abdomen derives from, or is associated with, Cold in the abdomen.


– Qing Pi, Chen Pi, Xiang Fu, Jie Geng and Huo Xiang move Qi and harmonize the Stomach.

– Rou Gui and Yi Zhi Ren warm the Lower Burner and scatter Cold.

– San Leng and E Zhu ‘break’ Blood and dissolve masses.

– Gan Cao, Sheng Jiang and Da Zao harmonize.


Women’s Treasure remedy


– FREEING CONSTRAINT

This remedy pacifies the Liver, moves Qi, eliminates stagnation, invigorates Blood, eliminates stasis and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is a body with Red or Purple sides.



Summary

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Jun 6, 2016 | Posted by in GYNECOLOGY | Comments Off on Abdominal Masses

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