Filed under Haematological Diseases
Professor Zhao Shao Qin’s Clinical Application of Sheng Jiang San in the Management of Haematological Diseases
By Dr Greta Young Jie De
Sheng Jiang San originated from “Shang Han Wen Yi Tiao Bian Systematic Differentiation of Warm Pestilence from Shang Han Lun” by Yang Li Shan of the Qing Dynasty. The herbal ingredients are Chen Tui 蝉蜕, Jiang Can 僵蚕, Pian Jiang Huang片姜黄 and Da Huang 大黄. This is a core formula used by Yang Li Shan 杨栗山 for treatment of external epidemic contraction of febrile diseases.
Professor Zhao Shao Qin, a prolific modern day Wen Bing specialist, was born in Beijing to a family with three generations of imperial physicians. In 1977, he was appointed head of the Wen Bing Faculty at the Beijing College of Traditional Chinese Medicine. The following is the application of Sheng Jiang San for treatment of haematological diseases by Professor Zhao Shao Qin.
Analysis of Sheng Jiang San:
- Jiang Can 僵蚕 and Chan Tui 蝉蜕 raise the clear yang, while Jiang Huang姜黄 and Da Huang大黄 direct turbid yin downwar By incorporating two ascending herbs and two descending herbs, the qi dynamic could be restored.
- The dual strategy of this formula is comparable to Liu He Jian’s刘河间 Shuang Jie San (Twin Releasing Powder), which also uses two different methods to achieve its goal of expelling toxicity from the interior to exterior.
- The combination of bitter and acrid flavours possess both ascending and descending actions thus regulating the qi dynamic.
- Acrid lifts the clear yang; bitter leads turbidity downwards
The combined effect of the four herbs vents constrained fire, invigorates blood and frees the obstruction of network vessels.
Idiopathic Thrombocytopenia Purpura
Idiopathic Thrombocytopenia Purpura (ITP) is defined as isolated low platelet count (thrombocytopenia) with normal bone marrow and the absence of other causes of thrombocytopenia. It causes a characteristic purpuric rash and an increased tendency to bleed. Two distinct clinical syndromes manifest as an acute condition in children and a chronic condition in adults. The acute form often follows an infection and has a spontaneous resolution within two months. Chronic immune thrombocytopenia persists longer than six months with a specific cause being unknown. From the Chinese medicine perspective ITP is regarded as blood deficiency with haemorrhage due to the inability of qi to astringe blood or spleen’s inability to manage blood. Professor Zhao suggested that in addition to the presence of blood deficiency, there is also heat binding with blood causing blood stasis. Hence the tongue is red and pulse is rapid. Treatment should not be warming and tonifying method. Instead, blood cooling and stasis transforming are more appropriate and the indicated formula is Sheng Jiang San modified.
Liu x 3 year-old male
History: The patient suffered from Idiopathic thrombocytopenia purpura. In March 1993 he was treated with steroid for several months but the result was not effective. Subsequently he consulted Professor Zhao.
Blood test: Blood platelet count: 30,000 mm3. His body was covered with bruises especially on the lower limbs with some bleeding spots merging into large patches.
S/S: Restless sleep, dark yellow urine, dry bowel movement, pale complexion with dry red lips; red tongue with prickles and a wiry and slippery pulse.
Diagnosis: Heat at the blood aspect.
Treatment principle: Cool blood and transform blood stasis.
Prescription: Sheng Jiang San modified
Chen Tui 蝉蜕6g; Da Huang大黄 1g; Pian Jiang Huang 片姜黄 6g; Jiang Can僵蚕 10g; Xiao Ji 小蓟10g; Chao Huai Hua炒槐花 10g; Bai Mao Gen 白茅根 10g. Seven packs.
After seven packs of medication, there was gradual reduction of bruises and his blood platelet count was 80,000/mm3. Continue with another seven packs of medication. His blood platelet count was 150,000/mm3. Continue with the same formula with minor modifications during the ensuing 3 months. During the treatment period, his blood platelet counts were 100,000~260,000/mm3 . This can be regarded as clinical recovery.
Aplastic anaemia is a rare disease in which the bone marrow and the hematopoietic stem cells that reside there are damaged . This causes a deficiency of all three blood cell types (pancytopenia): red blood cells (anaemia), white blood cells (leukopenia), and platelets (thrombocytopenia) . Aplastic refers to inability of the stem cells to generate mature blood cells. It is most prevalent in people in their teens and twenties, but is also common among the elderly. It can be caused by exposure to chemicals, drugs, radiation, infection, immune disease, and heredity. However, in about half the cases, the cause is unknown.
The clinical presentation is serious anaemia with recurrent haemorrhaging. Due to the reduced ability to ward off external contraction there can be recurrent secondary infection. Features associated with anaemia are lacklustre complexion or wilting complexion, pale lips and nails, fatigue, lethargy, heart palpitations and shortness of breath. Hence the normal rationale of treatment strategy would be tonification. Yet, approaches of tonifying blood or qi or spleen or kidney all have been demonstrated to yield unsatisfactory results. In reality the basic pathogenesis is constrained heat in the liver channel causing damage to the Ying blood. Damage to blood may cause deficiency while blood heat may cause frenetic flow of blood. In Chinese medicine theory, liver stores blood and governs dispersing. The constrained heat may disrupt the normal dispersing function of the liver causing heart vexation, irritability and dream-filled sleep. The impaired dispersing function of the liver may in turn disrupt the function of the triple jiao manifested as thick, turbid and greasy tongue coat. The constrained heat can damage blood with ensuing frenetic movement of blood, hence the wiry, thready and throbbing pulse. Therefore in spite of the bleeding, one must not use warming and tonifying methods. Instead, treatment should be to diffuse and disperse the constrained liver and gallbladder heat as illustrated in the following case.
Yuan x, 70 year-old male;
First consultation: March 1993
History: The patient suffered from aplastic anaemia for three years. Treatment using warming and tonifying strategy was not effective.
S/S: Wilting complexion, fatigue, lethargy, heart vexation, irritability, copious dreams at night; pale and swollen tongue with thick, turbid and greasy tongue coat and wiry, slippery, thready and rapid pulse.
Blood test: Haemoglobin 5g/L; WBC 2900/mm3; blood platelet 60,000/mm3.
Diagnosis: Constrained heat in the liver channel accompanied by damp heat obstruction in the middle jiao.
Treatment Principle: Clear liver and gallbladder heat, disperse and regulate the triple jiao.
Prescription: Sheng Jiang San modified
Chan Tui 蝉蜕6g; Chai Hu柴胡6g; Pian Jiang Huang片姜黄 6g; Jiao Mai Ya焦麦芽 10g; Jiao San Zha 焦山楂 10g; Shui Hong Hua Zi 水红花子10g; Da Huang大黄 1g; Jiang Can僵蚕 10g; Huang Qin 黄芩 10g; Jiao Shen Qu 焦神曲10g; Chuan Lian Zi 川楝子10g. 7 packs.
During the second consultation, the patient was more energetic. Blood test: Haemoglobin 9g/L and increased RBC and Blood platelet counts. Continue with the medication for a further two months to consolidate. Subsequently, his complexion was rosy and he continued to feel energetic. At the end of his treatment, blood tests showed that his haemoglobin counts continued to improve.
Leukemia is a group of cancers that usually begin in the bone marrow and result in high numbers of abnormal white blood cells. These white blood cells are not fully developed and are called blasts or leukemia cells. Symptoms may include bleeding and bruising problems, feeling tired, fever, and an increased risk of infections. These symptoms occur due to a lack of normal blood cells. Diagnosis is typically made by blood tests or bone marrow biopsy.The exact cause of leukemia is unknown. Different kinds of leukemia are believed to have different causes. Both inherited and environmental (non-inherited) factors are believed to be involved. Clinical presentations are haemorrhaging, anaemia and secondary infection. Traditional Chinese medicine approach is to tonify the deficiency. However, Professor Zhao Shao Qin suggested the aetiology can be attributed to hereditary or due to deep penetration of toxin resulting in heat toxin invading the bone marrow affecting the blood aspect. Hence the clinical manifestation reflects heat toxin in the blood aspect, and the indicated treatment is to cool blood and relieve toxicity.
Cui x, 16 year-old male
History: The patient suffered from chronic myelogenous leukemia for more than three years. After chemotherapy his condition was improved but not stable. Chinese medicine using tonifying herbs seemed to cause his condition to worsen.
He consulted Professor Zhao in April 1992. Blood tests showed presence of immature white blood cells.
S/S: Nose bleed, bitter taste in the mouth, dry throat, heart vexation, irritability, dreams at night, dry bowel movement and dark urination. His tongue was red with thick yellow tongue coat at the root, and his pulse was wiry, slippery, thready, rapid and forceful.
Treatment principle: Cool blood and relieve toxicity
Prescription: Sheng Jiang San modified
Chan Tui蝉蜕 6g; Qing Dai 青黛6g (to be added to decoction); Pian Jiang Huang 片姜黄 6g; Da Huang 大黄 2g; Sheng Di Yu 生地榆 10g; Chi Shao 赤芍 10g; Dan Shen 丹参 10g; Qian Cao 茜草 10g; Xiao Ji小蓟 10g; Ban Zhi Lian 半枝莲10g; Bai Hua She She Cao白花蛇舌草10g. 7 packs.
During his course of treatment in the next six months his blood tests showed a gradual reduction of immature white blood cells and his condition was stabilized. He continued the treatment with modifications.
Idiopathic Thrombocytopenia, Aplastic Anaemia and Leukemia are blood-related diseases with tendency of haemorrhaging and anaemia. Often they are thought to be a deficient pattern to be treated with tonifying strategy. Professor Zhao Shao Qin emphasized the significance of pattern identification and to treat accordingly. It is essential to focus on the pathogenesis and carefully observe the symptoms and signs by referring to the teaching of Nei Jing: “Zhi Zhen Yao Da Lun”, i.e., pay attention to the pathogenesis of the diseases …investigate the reason of the related syndromes and differentiate the difference between excess and deficiency, and then treat accordingly. For example, with reference to the case studies above, although they were characterised by blood deficiency, it is important to dwell on the root cause that led to the blood deficiency. Professor Zhao based on the patients’ symptoms of heart vexation, irritability, bitter taste in the mouth, dry throat, dry bowel movement, dark urination, wiry, slippery, rapid and forceful pulse and red tongue with yellow turbid greasy tongue coat concluded that they were constrained heat in the blood and obstruction in the collaterals by blood stasis, hence causing haemorrhaging. Since qi is the commander of blood and controls proper blood flow, the application of Sheng Jiang San is to regulate the qi dynamic coupled with blood cooling and toxin relieving herbs to address the syndrome of blood heat and toxicity. This is tantamount to the teaching in Nei Jing’s “Zhi Zhen Yao Da Lun”, which advocates the principle of dispersing the qi and blood to ensure normal flow in order to achieve the body’s balance of yin, yang, qi and blood.