CHAPTER 59 Breast Lumps
), the character yan being composed of a mountain and a rock which denote the hardness of the lump. Breast lumps, however, are also included in other breast conditions such as Ru Li (breast scrofula, 
), Ru Pi (breast lump, 
), and Ru Lao Tan (breast Phlegm-Exhaustion, or tuberculosis of the breast, 
). Of course, ancient Chinese medicine did not have a concept of cancer or malignancy and could not differentiate lumps according to benign and malignant. However, the doctors were well aware of the seriousness and poor prognosis of certain types of lump, and Ru Yan indicated a lump which was difficult to treat and often led to death, while Ru Pi, judging by its description, corresponds to a benign lump such as those found in fibroadenoma or cysts. The Concise Dictionary of Chinese Medicine defines Ru Pi as: a lump (or lumps) in the breast which is like a plum seed or an egg or nodules which feel hard and are painless and mobile. The breast does not feel hot or cold to the touch, the skin colour is unchanged and the size of the lump varies according to the mood of the woman.1
The Discussion on the Origin of Diseases (Zhu Bing Yuan Hou Lun, AD 610) mentions hard breast nodules (called ru shi yong 
, i.e. ‘breast stone carbuncle’) that cannot be moved on palpation. It says: “The Stone Carbuncle is not very big, not red nor hot … it is an accumulation like a stone” and “There is a hidden accumulation in the breast without pain or itching.” Also: “There is an accumulation under the skin like a cow’s neck.” 2
If it is not broken it can be treated, if it is broken it is difficult to treat. The earlier it is treated, the better. If it bursts inside it burns the flesh, it spreads to the internal organs and causes death.3
Chen Bai Ming in the Beneficial Formulae of the Great Compendium of Gynaecology (Fu Ren Da Quan Liang Fang, 1273) differentiates between breast carbuncle (yong 
) and lump (yan 
) saying that the former is characterized by redness, swelling and heat, the latter by its process of development:
in the beginning there is a small accumulation like a turtle egg which is not red nor painful, after several months it gets bigger, then the lump breaks up like a ripe pomegranate, it bursts through like in a deep hole, this is due to Liver and Spleen being affected by anger, Qi and Blood are exhausted and it is called Ru Yan.4
Zhu Dan Xi (Yuan dynasty, 1281–1358) discussed the treatment of breast lumps in detail. He said:
Worry, anger and depression cause accumulation, Spleen-Qi is weakened, Liver-Qi free flow fails, there is a hidden nodule formed like an egg without pain or itching; after several years it forms an ulcer (chuang 
) and it is called Ru Yan. It looks like an ulcer on the surface and is like a stone in a cavity, it cannot be treated.5
In the beginning it is like a bean, then like an egg, without pain or itching, after one year pain develops. Then it grows into a heap, the skin becomes purple, then ulcers develop and the lump is like a rock, there is blood oozing from the nipple, then the five Yin organs are exhausted.6
) and breast cancerous lumps (ru yan). He highlights the following as the main differences between these two pathologies:A swelling of the breast with red nodules that lasts several days with pain and oozing of pus which then heals, is due to Toxic Heat in Stomach and Gall-Bladder with stagnation of Qi and Blood and it is called Breast Carbuncle: this is easy to treat. If inside the breast there are small nodules, not red, not swollen and not painful, but which last for months forming [a lump] like a rocky mountain, and then like a ripe pomegranate when they break, these are difficult to treat.8
The discussion in this chapter will be confined to benign lumps only. The treatment principles and prescriptions used for breast cancer are quite different from those used for benign breast lumps; however, the aetiology, pathology and differentiation of breast lumps is the same, whether benign or malignant. Indeed, the ancient Chinese doctors quoted above obviously did not know the difference between a benign lump and a malignant one and, therefore, the aetiology, pathology and differentiation which they identified were the same for benign or malignant lumps.
However, it is interesting to note that, although the ancient doctors could not know the difference between a benign or malignant lump, they were well aware of symptoms and signs indicating a poor prognosis. For example, the quotation from Zhu Dan Xi reported above clearly ends by saying that, in the presence of the symptoms and signs described, the patient “cannot be treated”. Similarly, the Ming dynasty doctor quoted above refers to the spread of the disease from the breast to the “Five Yin organs”, a reference that can be interpreted as metastasis from a malignant lump.
Aetiology
Emotional problems
Emotional problems are by far the most important cause. Worry, pensiveness, sadness, ‘bitter weeping’, anger, frustration, resentment, hatred, repressed anger and guilt can all cause stagnation of Qi which in the long run may lead to Blood stasis which forms masses. Stagnant Qi, over a long period of time, may also ‘implode’ to cause Fire and Toxic-Heat.
It is important to realize that stagnation of Qi comes not only from the Liver but also from the Heart and the Lungs. In fact, even emotions that cause depletion of Qi, such as sadness and grief, may cause stagnation of Qi (of the Lungs) because, when Qi is depleted in the chest, it does not circulate well and therefore stagnates.
In the particular case of breast lumps, the stagnation of Qi of the Lungs and Heart is particularly relevant because these two organs and channels are situated in the chest. Zhu Dan Xi says:
When a woman is worried and depressed, accumulation develops, Spleen-Qi becomes weak, Liver-Qi rebels horizontally, stagnant Qi turns into nodules like turtle eggs, there is no pain or itching. After ten years ulcers develop and the disease is called Ru Yan.9
Furthermore, it is important to remember that stagnation of Qi in women is very often secondary, as it may be the consequence of a deficiency of the Liver and Kidneys affecting the Directing and Penetrating Vessels (Ren and Chong Mai).
The Orthodox Manual of External Diseases (Wai Ke Zheng Zong), written by Chen Shi Gong in 1617, mentions the Heart in connection with stagnation when it says: “Depression injures the Liver, pensiveness affects the Spleen, accumulation develops in the Heart, the channel-Qi stagnates and generates nodules.”10
Disharmony of the Directing and Penetrating Vessels (Ren and Chong Mai)
Disharmony of the Directing and Penetrating Vessels after the menopause results from the cessation of the periods causing a relative imbalance between the top and bottom parts of the body. The Lower Burner is deficient in Blood and Essence so that the Qi of the Penetrating Vessel may rebel upwards and cause stagnation above. The Penetrating Vessel originates from the Uterus (in women) and connects with the breast and there is a connection between the uterus Blood and breast milk. In fact, a saying states that “the Uterus is the lower source of milk and the breast is the upper source of Blood”. Thus the drying up of Blood and Essence below may cause stagnation in the breast and lead to lumps.
The main Penetrating Vessel symptom, called Li Ji, results from rebellious Qi rising from the abdomen to the chest; Li Ji indicates, on the one hand, ‘a feeling of anxiety’ and, on the other hand, a feeling of constriction (or contracture) of the chest. These phenomena are related to the Penetrating Vessel and have an effect on the pathogenesis of breast lumps and cancer.
Because of the Penetrating Vessel’s influence on the Uterus and breast, some Chinese books also mention abortion, miscarriage and lack of breastfeeding as contributory factors in breast lumps.
In my opinion, what Chinese books call ‘disharmony of the Directing and Penetrating Vessels’ is also caused by hormonal manipulation throughout a woman’s lifetime. This may derive from the use of the contraceptive pill, the hormonal stimulation for assisted fertilization and also hormones present in foods and the environment.
Irregular diet
Excessive consumption of dairy foods, fats and sweets leads to Phlegm which may form lumps. This is an important contributory cause of breast lumps in Western women.
Overwork
Overwork, in the sense of working long hours without adequate rest and with an irregular routine and diet, weakens Liver- and Kidney-Yin. Liver-Yin is the root of Liver-Qi, the Liver is the ‘root of stopping extremes’, i.e. the harmonizing organ that needs a balance between its Yin and Yang part. Deficiency of Liver-Blood or Liver-Yin may often lead to stagnation of Liver-Qi. Very often stagnation of Liver-Qi is secondary to Liver-Blood or Liver-Yin deficiency: when this happens, a woman has all the symptoms of Liver-Qi stagnation but a Choppy pulse and Thin-Pale tongue.
Pathology and treatment principles
The pathology of breast lumps is complex. Stagnant Qi (of Liver–Lungs–Heart–Stomach) leads to accumulation in the channels, the breast Connecting channels are obstructed and stagnation of Qi leads to stasis of Blood. Stagnation of Qi and deficiency of the Spleen lead to Phlegm which accumulates in the breast. Disharmony of the Directing and Penetrating Vessels with Emptiness (of Blood and Essence) below and Fullness above leads to accumulation in the breast. Stagnant Qi can turn into Fire after a long period of time and this, in turn, may become Toxic-Heat. Fire and Toxic-Heat injure Yin and lead to Liver and Kidney deficiency.
In terms of channels, the Directing and Penetrating Vessels are the most important ones in the development of breast lumps. Both Directing and Penetrating Vessels arise from the space between the kidneys, flow through the uterus and connect upward with the breasts (see Fig. 59.1).
The stagnation of Liver-Qi that is nearly always the beginning stage of breast lump development is closely related to the Kidneys and this relationship takes place within the Directing and Penetrating Vessels. When the Kidneys are weak, the Directing and Penetrating Vessels are also weak in the Lower Burner: when Kidney-Qi is deficient, the Liver may lose its free flow and the combination of these two factors upsets the normal functioning of the Directing and Penetrating Vessels. This results in Emptiness below and Fullness above in these two vessels. Thus, the treatment principle must be based on tonifying the Kidneys and consolidating the Directing and Penetrating Vessels below, and moving Qi, eliminating stagnation and subduing rebellious Qi above.
The Directing and Penetrating Vessels also influence the formation of breast lumps in other ways, through the Gao (
) and Huang (
) structures. Gao literally means ‘fat’ while Huang means ‘membranes’: the Source points for these two structures are both on the Directing Vessel. Chapter 1 of the Spiritual Axis mentions the Source points as being the following:
The Spiritual Axis says literally: “The Source of Gao comes out at Jiuwei, one point. The Source of Huang comes out at Bo Yang, one point.”11 All Chinese texts and dictionaries say that Bo Yang is Ren-6 Qihai, but some people think it is Ren-8 Shenque. However, note that an alternative name for Ren-6 Qihai is ‘Xia Huang’, i.e. ‘Lower Membranes’: this would seem to confirm that the point Bo Yang mentioned in Chapter 1 of the Spiritual Axis is indeed Ren-6 Qihai (see also Ch. 7).
Gao (‘fat’) may refer to adipose tissue. An interesting aspect of this is that old Daoist texts on embryology say that in the first month, the fetus (or, more precisely, blastocyst) is just ‘Gao’ say that the fetus in the second month is ‘Gao’). Huang literally means ‘membranes’ and it refers to tissues surrounding and connecting the viscera. Chapter 40 of the Simple Questions mentions Huang:
Some people are affected by swelling of the large joints and abdominal pain around the umbilicus: what is the cause of this disease? [the Yellow Emperor asks] Chi Po answers: This disease is called Hardness of the Viscera and is due to Wind. When this overflows to the Large Intestine it reaches the Huang Membranes, the Source of the Huang Membranes is below the umbilicus and this causes pain around the umbilicus.12
The Classic of Categories (1624) says: “The gaps running up and down the abdomen in between the muscles of abdominal cavity are where the Huang Membranes are situated”.13 This last passage clearly seems to indicate that the Huang membranes are the connective tissue in the abdominal cavity that encapsulates and connects the viscera.
Thus, Gao and Huang represent a whole range of connective tissue including adipose tissue and abdominal connective tissue. They cover the whole body with a layer immediately below the skin and an inner layer wrapping and anchoring the organs, muscles and bones. In other words, Gao and Huang are all the structures that are not skin, muscles, sinews, blood vessels, bones or internal organs. When we refer to the tissues of the body related to the five main Yin organs, we normally include skin (Lungs), muscles (Spleen), sinews (Liver), bones (Kidneys) and vessels (Heart); however, if these were the only tissues, the organs would be situated in a vacuum unconnected to each other or to surrounding structures. We know from modern medicine that the connective tissue does indeed connect, i.e. it connects various structures of the body. In the abdominal cavity, Gao corresponds to adipose tissue and Huang to the connective tissue and the capsules surrounding the organs (Fig. 59.2). There are other types of connective tissues such as the tendons, which pertain to the ‘sinews’.
With reference to the two points Ren-15 and Ren-6 (or Ren-8), these are the Source of Gao and Huang, which means that these points and the whole Directing Vessel on the abdomen are embryologically related to the development of abdominal connective tissue. Using these points can therefore act at a deep energetic level to regulate and equalize tensions and weaknesses in the ‘membranes’ of the abdomen and thorax. In relation to the breast, this is rich in adipose tissue and connective tissue, the latter in the form of compartments that house the glandular lobules (see Fig. 59.3). Thus, both the Directing and Penetrating Vessels exert an important influence on the breast through the Gao and Huang structures (as well as in other ways). Figure 59.4 illustrates the relation between these two vessels and breast structures.
A stagnation of Qi in the Directing and Penetrating Vessels, and especially in the latter, will therefore induce a state of tension and congestion in the Gao and Huang structures of the breast and obstruct the channels, vessels and Connecting channels of the breast: all these are related to the Penetrating Vessel because this vessel governs all Connecting channels (as it is the Sea of the Twelve Channels) and the blood vessels (as it is the Sea of Blood). Long-term stagnation of Qi will eventually lead to accumulation of Phlegm and stasis of Blood, both important factors in the pathogenesis of breast lumps.
The Huang structures (and therefore the Directing and Penetrating Vessels) are also involved in the pathogenesis of breast cancer, even though this is a carcinoma, i.e. cancer of the epithelial tissue. In fact, in recent years researchers have suggested that some of the non-glandular supporting cells within the breast (made of connective tissue and therefore Huang) may influence the growth of cancer cells. These cells form part of the supporting structure of the breast and produce some chemical messengers called growth factors which seem to ‘communicate’ chemically with breast cancer cells to influence both their growth and their ability to spread.14
), literally ‘penetrating the breasts Luo (channels)’. All these herbs will have an action in moving Qi and Blood in the Penetrating Vessel because of the relation between this channel and the Connecting channels and blood vessels. The main herbs that have this function are:It is interesting to note that some of these herb names contain the words Luo for Connecting channels and Tong for ‘removing obstructions’. Moreover, the structure of these herbs when dried resembles a network of channels running in all directions, just as the network of Connecting channels does. In some of them, the structure even resembles the network of the breasts with its lobules, milk ducts and connective tissue compartments. In particular, Ju Luo Fibra Citri rubrum, i.e. the soft fibrous tissue lining the inside of the rind in tangerines, bears a close resemblance to the connective tissue inside the breast, and the whole fruit may be taken to represent the breast itself (see Fig. 59.5).
The main pathogenic conditions in breast lumps are therefore:
The last two are more common in older women. However, every case is characterized by deficiency in its initial stages and by simultaneous excess and deficiency in its middle to late stages. Since each case is characterized by both a deficiency and an excess, the crucial question is whether to tonify the body’s Qi (bu zheng), eliminate pathogenic factors (gong xie) or do both simultaneously. Generally speaking, one tonifies the body’s Qi and eliminates pathogenic factors simultaneously but always with the emphasis on one or the other. This means that, when using herbal medicine especially, one has to have a clear idea in mind as to the chosen treatment principle and consequent chosen formula. Although every formula is modified to take into account tonifying the body’s Qi or eliminating pathogenic factors, the choice of where to put the emphasis is still crucial.
In the initial stages, the treatment principle usually adopted is to tonify the body’s Qi and especially the Liver and Kidneys. Thus, for example, if a woman presents with a very small lump that has been detected by mammography and there are no prominent symptoms of a breast pathology in a Chinese sense (no obvious swelling, redness, heat and, most of all, no palpable lump), the emphasis of the treatment should probably be on tonifying the body’s Qi; however, whatever tonifying formula is chosen, it should always be modified to include herbs that eliminate pathogenic factors and move Qi or resolve Phlegm or both. If, on the contrary, a woman presents with an obvious lump or lumps in the breast which have been proven to be benign in nature and the breast is swollen, hot and tender, then the treatment principle should be to eliminate pathogenic factors primarily by moving Qi, invigorating Blood, resolving Phlegm, removing obstructions from the breast’s Connecting channels or resolving Toxic-Heat. Again, whatever eliminating formula is chosen, it should be modified with the addition of some herbs to tonify the body’s Qi and, in particular, the Liver and Kidneys.
With acupuncture, the distinction between tonifying the body’s Qi and eliminating pathogenic factors is less clear cut but it does, nevertheless, exist both in the choice of points and in the choice of needling technique. With regard to the choice of points, tonifying the body’s Qi implies choosing tonic points such as KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue and BL-23 Shenshu for the Kidneys, and LIV-8 Ququan, SP-6 Sanyinjiao, BL-18 Ganshu and Ren-4 Guanyuan for the Liver. If Blood needs to be tonified, one would use points such as LIV-8 Ququan, SP-6 Sanyinjao, ST-36 Zusanli, BL-17 Geshu and Ren-4 Guanyuan. With regard to eliminating pathogenic factors, one would use points such as SP-9 Yinlingquan, SP-6 Sanyinjiao, Ren-9 Shuifen, ST-28 Shuidao, ST-40 Fenglong and BL-22 Sanjiaoshu to resolve Dampness and Phlegm; points such as Ren-6 Qihai, SP-10 Xuehai, LIV-3 Taichong, KI-14 Siman, T.B.-6 Zhigou, P-6 Neiguan, LIV-14 Qimen and BL-18 Ganshu to move Qi and invigorate Blood; and points such as L.I.-11 Quchi, Ren-12 Zhongwan, SP-10 Xuehai, LIV-2 Xingjian, P-8 Laogong or G.B.-41 Zulinqi to resolve Toxic-Heat. In terms of needling technique, this should obviously be reinforcing to tonify the body’s Qi and reducing to eliminate pathogenic factors.
Diagnosis
Palpation is essential, not to replace the diagnosis of an expert gynecologist, but because it gives us therapeutic guidelines:
Table 59.1 summarizes the different types of breast lumps, with their symptoms, tongue, pulse, treatment principle and prescription.
Channels
It is useful at this point to review the channels coursing over the breasts (Fig. 59.6).
Main channels
The Stomach channel goes over the breast and many of its points are important for the breast, e.g. ST-18 Rugen, ST-12 Qupen, ST-36 Zusanli, ST-41 Jiexi. It affects the breast as a whole, and also via the Penetrating Vessel which connects to the Stomach at ST-30 Qichong. The production of breast milk after childbirth is a transformation of Blood from the Sea of Blood of the Penetrating Vessel into milk.
The Liver channel goes over the sides of the breast and specifically influences the nipple. Liver points which affect the breast are LIV-3 Taichong and LIV-14 Qimen.
Extraordinary Vessels
The Penetrating Vessel scatters over the chest and has an important influence on the breast also because it represents the channel connection between the Uterus (where it starts) and the breasts. In other words, the Penetrating Vessel is the channel embodiment of the Western hormonal connection between the ovaries/uterus and the breasts. The pathology of the Penetrating Vessel has a great bearing on the formation of breast lumps. When there is a disharmony of this vessel in the Lower Burner (with Blood deficiency or Kidney deficiency), very often Qi rebels upwards to disturb the chest and cause stagnation of Qi in the chest and breasts. This is a major factor in the development of breast lumps.
Muscle channels
The Gall Bladder muscle channel goes over the breast. In fact, G.B.-41 Zulinqi is an important point for the breast.
The Stomach muscle channel goes over the breast.
Both the Pericardium and Heart muscle channels go over the breast: this highlights the physiological connection between emotional factors affecting the Heart and Pericardium and breast lumps. It should be remembered that stagnation of Qi may affect the Heart in the chest.
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