Treating Myelodysplastic Syndrome with Chinese Medicine. Introduction. by Simon Becker, Dipl. Ac. & C.H. (NCCAOM)

Transcription

1 Treating Myelodysplastic Syndrome with Chinese Medicine by Simon Becker, Dipl. Ac. & C.H. (NCCAOM) Introduction Myelodysplastic Syndrome (MDS) is a type of anemia resulting from clonal proliferation of abnormal stem cells. As such, it is very similar to aplastic anemia. All MDS symptoms result from pancytopenia (a deficiency of all formed elements of the blood) of varying severity. Western medicine has not been able to link a definite cause to the development of this disease; however, some patients have evidence of exposure to toxic chemicals, most notably benzene. Furthermore, the use of alkylating chemotherapeutic drugs is also associated with a risk of subsequent MDS. Pathologically, the bone marrow is normal or hypercellular, and, because of ineffective hemopoiesis, there are variable cytopenias (cell deficiencies), the most frequently seen being anemia (red blood cell deficiency). If there is extramedullary hemopoiesis, there will be subsequent enlargement of the spleen and liver. The WBC count may be normal, increased, or decreased. Clinical manifestations are highly variable. MDS may smolder for years and require only occasional blood transfusions or antibiotics for infections. However, the disorder transforms into acute myelogenic leukemia in about 20 to 40% of patients. Western medical treatment has so far only been experimental, and the use of chemotherapeutic agents has been largely ineffective. Therefore, Western medical therapy focuses on supportive care with RBC transfusions as indicated, platelet transfusions for bleeding, and antibiotic therapy for episodes of infection. MDS is commonly classified according to the FAB (French-American-British) system. Classification strongly correlates to severity of clinical symptoms and possibility of development of acute myelogenic leukemia. This means that MDS-RA and MDS-RAS manifest with less severe clinical symptoms and often respond better to treatment, both Western as well as Chinese. MDS-RAEB and MDS-RAEBT are acute diseases manifesting with severe symptoms with a life expectancy of only half a year. All types of MDS may transform into each other, beginning with the least severe type (MDS-RA) and progressing to the most severe type (MDS-RAEBT). MDS-RAEBT then commonly transforms into acute myelogenic leukemia, a rapidly fatal disease. Refractory anemia (RA) RA with sideroblasts (RA-S) RA with excess blasts (RAEB) Patients may survive for several years with expected median survivals of 2 to 3 years. Less likely to demonstrate progression to the more aggressive forms and patients may die from unrelated causes Median survival of one and a half years RAEB in transformation (RAEB-T) Median survival of half a year In the Chinese-language Chinese medical literature, information on the treatment of MDS with either Chinese medicine alone or a combination of Western and Chinese medicine is rare. Hence, the chapter in

2 my A Handbook of Chinese Hematology 1 was based on the few articles that had been published in professional Chinese medical journals and my observation of MDS patient treatments at the hematology department of the Heilongjiang University Hospital in Harbin, China. As such, my discussion was very clinically oriented and based on relatively scant information. In the middle of 2000, my teacher and head of the hematology department at the above-named hospital, Dr. Sun Wei-zheng, edited and published the first comprehensive textbook on Chinese medical hematology in Chinese: Zhong Yi Xue Ye Bing Xue (Study of Chinese Medical Hematology) 2. This book included, for the first time in the Chinese medical literature, a comprehensive discussion of MDS. Also, this discussion represents the current Chinese medical standards of care for the treatment of MDS. Hence, as a supplement to the chapter on MDS in my own book, below I render a functional translation of the Myelodysplastic Syndrome chapter in Dr. Sun s book. Furthermore, as the publication of articles on the Chinese medical treatment of MDS are rare, following Dr. Sun s theoretical discussion of MDS is a functional translation of an article titled Observation of the treatment effect of using Qing Du Yin (Clear Toxin Drink) and Yang Zheng Pian (Nourish The Righteous Tablets) in the treatment of 10 cases of Myelodysplastic Syndrome (MDS) that was published in the Xin Zhong Yi (New Chinese Medicine) in April of Functional translation of: Myelodysplastic Syndrome (MDS) chapter in Zhong Yi Xue Ye Bing Xue (Study of Chinese Medical Hematology) MDS does not exist in Chinese medicine. However, according to its manifestations, it belongs to the Chinese medical disease categories of vacuity taxation (xu lao), blood vacuity (xue xu) 4, concretions and accumulations (zheng ji), and warm taxation (wen lao). The common disease causes are natural endowment insufficiency, loss of regulation of food and drink, severe or prolonged diseases, and viscera and bowel vacuity weakness with gathering of toxins. The kidneys are the earlier heaven source and store the essence qi of the five viscera and six bowels; the kidneys also govern bones, engender marrow, and store essence; further, essence transforms blood. If natural endowment is insufficient, then engenderment and transformation lose their source; hence, the common root of this disease, namely qi vacuity, blood vacuity, and essence depletion, arise. 1 Simon Becker, A Handbook od Chinese Hematology, Blue Poppy Press, Boulder, CO, Zhong Yi Xue Ye Bing Xue (Study of Chinese Medical Hematology), Sun Wei-zheng, ed., National Chinese Medicine Science and Technology Publishing House, Beijing, Yang Hong-yong et al., Observation of the treatment effect of using Qing Du Yin (Clear Toxin Drink) and Yang Zheng Pian (Nourish The Righteous Tablets) in the treatment of 10 cases of Myelodysplastic Syndrome (MDS), Xin Zhong Yi (New Chinese Medicine), #4, 1998, p In an article I published in Acupuncture Today (August 2000), I listed, just like in the translation above, blood vacuity (xue xu) as a traditional Chinese medical disease category commonly used in Chinese medical hematology. I was then criticized for confusing pattern discrimination and disease discrimination by an American Chinese medical practitioner who obviously does not read Chinese and has never consulted the Chinese medical hematology specialty literature. My point in saying all this is that blood vacuity (xue xu) truly is a commonly used traditional disease category in the field of Chinese hematology, regardless of the fact that it can also be a pattern of disharmony.

3 The spleen and stomach are the latter heaven root of qi and blood engenderment and transformation. If food and drink are not regulated, or if one eats excessive sweet and rich foods or drinks excessive alcohol, then the spleen and stomach are damaged and detrimented and therefore cannot transform and engender the finest essence from food and drink. Hence, qi and blood become vacuous, the viscera and bowels and channels and network vessels lose nourishment, and the vacuity at the root of this disease arises. Prolonged diseases will lead to a vacuity and prolonged diseases will also cause stasis. Vacuity will lead to repletion. If qi and blood are insufficient, then qi becomes stagnant and blood static; this can further cause phlegm nodulation, scrofula 5, abdominal glomus lumps, and static macules on the tongue. Hence, if a prolonged or severe disease leads to vacuity, repletion may arise, giving rise to the mixture of root vacuity and branch repletion commonly characterizing this disease. If the viscera and bowels are weak and vacuous, the entire body is weak and vacuous; hence the six external evil toxins may be contracted. When external evils enter the body, they often transform heat; heat then scorches and damages the bodily fluids and affects the blood network vessels. This causes blood to collect and stagnate in the network vessels, blood vessels, and viscera and bowels, thus leading to stasis. If the fluid metabolism loses its normalcy secondary to viscera and bowel weakness, then phlegm dampness accumulates and phlegm and stasis combine and obstruct, leading to such symptoms as dark mouth and lips, static macules of the mucous membranes, and concretion lumps. According to these four causes and mechanisms of disease engenderment, four patterns are discriminated: spleen and stomach depletion and vacuity, kidney essence depletion and vacuity, blood stasis phlegm obstruction, and evil toxins assailing. Treatment based on pattern discrimination 1) Spleen and stomach depletion and vacuity pattern Main symptoms: Withered yellow facial complexion, pale nails, dizziness, fatigued spirit, lack of strength, heart palpitations, shortness of breath, loose stools, torpid intake, abdominal distension, a pale and enlarged tongue, and a moderate and weak pulse. Treatment principles: Fortify the spleen and harmonize the stomach, boost qi and engender blood Treatment formula: Gui Pi Tang Jia Jian (Modified Return the Spleen Decoction) 6 Radix Panacis Ginseng (Ren Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhu), Sclerotium Pararadicis Poriae Cocos (Fu Shen), Semen Zizyphi Spinosae (Suan Zao Ren), Radix Angelicae Sinensis 5 Scrofula here is a technical term of Chinese medicine and should not be confused with the Western medical term scrofula, referring to tuberculosis of the lymph nodes. Scrofula are lumps beneath the skin down the side of the neck and under the armpits. Scrofula starts as bean-like lumps, associated with neither pain nor heat. Subsequently the lumps expand and assume a string-like formation, merge, and even bunch up into heaps. They are hard and do not move under pressure. In the latter stages, they may become slightly painful. They can rupture to exude a thin pus and sometimes contain matter that resembles bean curd dregs. 6 All of the formulas Dr. Sun presents are followed by jia jian (i.e, modified) although their listed ingredients are actually no modification of the original formulas. With this, Dr. Sun highlights that the formulas given here are merely guiding formulas for their corresponding patterns and always need to be modified in clinical practice. For most formulas, he lists some of the more common modifications.

4 (Dang Gui), Radix Astragali Membranacei (Huang Qi), Radix Auklandiae Lappae (Mu Xiang), honey mix-fried Radix Glycyrrhizae (Gan Cao), Radix Polygalae Tenuifoliae (Yuan Zhi), Arillus Euphoriae Longanae (Long Yan Rou). Formula explanation and modifications: Gui Pi Tang is a combination of Si Jun Zi Tang (Four Gentlemen Decoction) and Dang Gui Bu Xue Tang (Angelica Supplement the Blood Decoction) with additions. Si Jun Zi Tang supplements the qi and fortifies the spleen. Dang Gui and Huang Qi boost qi and engender blood. Suan Zao Ren, Yuan Zhi, and Long Yan Rou supplement the heart and boost the spleen, quiet the spirit and calm the mind. Mu Xiang rectifies qi and arouses the spleen, ensuring that the supplementing medicinals do not cause stagnation. Altogether, these medicinals supplement and nourish qi and blood, fortify the spleen and nourish the heart, and boost qi and contain blood. In order to strengthen the bleeding-stopping function of this formula, one can add Herba Agrimoniae Pilosae (Xian He Cao), Rhizoma Bletillae Striatae (Bai Ji) and Flos Immaturus Sophorae Japonicae (Huai Hua). For qi vacuity with descending and downbearing and lesser abdominal distension, add Radix Cimicifugae (Sheng Ma) and Radix Bupleuri (Chai Hu); these medicinals, combined with the source formula s Huang Qi, Dang Shen, and Bai Zhu, boost qi and upbear clear yang. For widespread bleeding, add Herba Seu Radix Cirsii Japonici (Da Ji), Herba Cephalanoplos Segeti (Xiao Ji), Radix Rubiae Cordifoliae (Qian Cao Gen), and Radix Lithospermi Arnebiae (Zi Cao). 2) Kidney essence depletion and vacuity pattern Main symptoms: White and lackluster facial complexion, dizziness, lack of strength, aching low back and limp knees, tinnitus, and forgetfulness; if kidney yin is vacuous, there also manifest such signs as tidal fever, night sweats, vexing heat in the five hearts, a red tongue with scant fur, and a fine and rapid pulse; if kidney yang is vacuous, there also manifest such signs as impotence, aversion to cold, cold limbs, a pale tongue with white fur, and a deep, fine, and forceless pulse. Treatment principles: Supplement and boost kidney qi, secure the kidneys and stop bleeding, or enrich yin and supplement the kidneys, cool blood and stop bleeding Treatment formula: Shen Qi Wan Jia Jian (Modified Kidney Qi Pill) Cooked Radix Rehmanniae (Shu Di), Fructus Corni Officinalis (Shan Zhu You), Radix Dioscoreae Oppositae (Shan Yao), Cortex Moutan Radicis (Dan Pi), Rhizoma Alismatis (Ze Xie), Sclerotium Poriae Cocos (Fu Ling), Radix Praeparatus Lateralis Aconiti Carmichaeli (Fu Zi), Ramulus Cinnamomi Cassiae (Gui Zhi) Formula explanation and modifications: Shu Di enriches yin and boosts the kidneys, replenishes essence and boosts the marrow. Shan Zhu You arouses, warms and enriches the kidneys and boosts the liver. Shan Yao enriches the kidneys and supplements the liver [sic; this is a possible typo and the correct character should be spleen rather than liver]. Together, these three medicinals strongly supplement kidney yin. Ze Xie combines with Shu Di to drain the kidneys and downbear turbidity; Dan Pi combines with Shan Zhu You to drain liver fire; and Fu Ling combines with Shan Yao to percolate spleen dampness. Hence, the three supplementing medicinals replete and supplement but are not slimy (i.e., their sliminess is controlled by the paired draining and dampness percolating medicinals). In addition, Fu Zi and Gui Zhi, both acrid and hot medicinals, invigorate life-gate fire to warm yang and transform qi. If kidney yin is vacuous, Gui Zhi and Fu Zi need to be removed from Shen Qi Wan and Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu) and Cortex Phellodendri (Huang Bai) need to be added to enrich yin and downbear fire. To clear and abate vacuity heat, add Cortex Radicis Lycii Chinensis (Di Gu Pi) and Radix Cynanchi Baiwei (Bai Wei). If kidney

5 yang is vacuous, add Radix Morindae Officinalis (Ba Ji Tian), Herba Epimedii (Xian Ling Pi), and Herba Cistanchis Deserticolae (Rou Cong Rong) to warm yang and supplement the kidneys and Folium Artemisiae Argyi (Ai Ye) and blast-fried Rhizoma Zingiberis (Pao Jiang) to warm the middle and stop bleeding. 3) Blood stasis phlegm obstruction pattern Main symptoms: Dark facial complexion, incrusted skin 7, conglomeration lump in the abdomen, phlegm nodulation, scrofula, a dark pale tongue with static macules, and a bowstring and choppy pulse. Treatment principles: Quicken blood and transform stasis, soften hardness and transform phlegm Treatment formula: Tao Hong Si Wu Tang He Fu Ling Wan Jia Jian (Modification of Peach Kernel and Safflower Four Materials Decoction and Poria Pills) Semen Pruni Persicae (Tao Ren), Flos Carthami Tinctorii (Hong Hua), Radix Angelicae Sinensis (Dang Gui), cooked Radix Rehmanniae (Shu Di), Radix Ligustici Wallichii (Chuan Xiong), Radix Paeoniae Lactiflorae (Shao Yao), Sclerotium Poriae Cocos (Fu Ling), Fructus Citri Aurantii (Zhi Ke), Rhizoma Pinelliae Ternatae (Ban Xia), Mirabilitum (Mang Xiao), Cortex Magnoliae Officinalis (Hou Po) Formula explanation: Tao Ren and Hong Hua quicken blood and transform stasis; Dang Gui supplements and harmonizes blood; Shu Di replenishes essence and boosts marrow; Chuan Xiong moves qi and quickens blood. Ban Xia, Hou Po and Mang Xiao soften hardness and transform phlegm. Fu Ling fortifies the spleen to eliminate the source of phlegm engenderment. Zhi Ke moves qi, disperses accumulation, and transforms phlegm. Altogether, the above medicinals quicken blood and transform stasis, soften hardness and transform phlegm. 4) Evil toxins assailing pattern Main symptoms: Vigorous fever, thirst, desire for cold liquids, headache, body pains, vexation and agitation, swollen and painful throat, ulceration of the mouth, short and reddish urination, dry and bound stools, red tongue with yellow fur, and a surging and rapid pulse. Treatment principles: Clear fire and resolve toxins, cool the blood and stop bleeding Treatment formula: Hua Ban Tang Jia Jian (Modified Transform Macules Decoction) Gypsum (Shi Gao), Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu), Cornu Bubali (Shui Niu Jiao), Radix Scrophulariae Ningpoensis (Xuan Shen), Radix Glycyrrhizae (Gan Cao) Formula explanation and modifications: Shi Gao and Zhi Mu clear heat and drain fire. Shui Niu Jiao and Xuan Shen clear heat, resolve toxins, nourish yin, cool the blood, and stop bleeding. To more strongly clear heat and resolve toxins, add Herba Taraxaci Mongolici Cum Radice (Pu Gong Ying), Herba Violae Yedoensitis Cum Radice (Zi Hua Di Ding), and Fructus Forsythiae Suspensae (Lian Qiao). For a swollen and painful throat with mouth ulcerations, add Radix Platycodi Grandiflori (Jie Geng), Radix Isatidis Seu Baphicacanthi (Ban Lan Gen), 7 Incrusted skin (ji fu jia cuo), often also called encrusted skin, refers to dry rough scaly and hardened skin. It is usually observed in emaciated patients with abdominal fullness and inability to eat.

6 Pulvis Indigonis (Qing Dai), and Rhizoma Bletillae Striatae (Bai Ji). Functional translation of Observation of the treatment effect of using Qing Du Yin (Clear Toxin Drink) and Yang Zheng Pian (Nourish The Righteous Tablets) in the treatment of 10 cases of Myelodysplastic Syndrome (MDS) by Yang Hong-yong et al.; Xin Zhong Yi (New Chinese Medicine), #4, 1998, p Qing Du Yin (Clear Toxin Drink) and Yang Zheng Pian (Nourish Righteous Tablets) are currently being studied by a Chinese medical task-force from Guangdong as to their effect in the treatment of cells dying from induced acute leukemia. Hence, since acute leukemia and MDS share similar characteristics in Chinese medicine, such as a root vacuity and branch repletion with qi and blood, yin and yang, and spleen and kidney depletion and vacuity as the root and phlegm turbidity, static blood, and toxic heat as the branch, the authors concluded that these two medicines may also effectively treat MDS. Hence, in this clinical audit, they used Qing Du Yin and Yang Zheng Pian in the treatment of 10 cases suffering from different stages of MDS. Out of the 10 cases, 7 were male and 3 were female; their age ranged from 16 to 53 years old; and the disease course varied from half a year to 2 years. According to the French-American-British (FAB) classification system, 4 cases suffered from MDS-RA, 1 case suffered from MDS-RAS, 3 cases suffered from MDS-RAEB, and 2 cases suffered from MDS-RAEBT. Their main clinical symptoms were as follows: somber white and lackluster or black facial complexion, fatigue and lack of strength, fever, vexing heat in the five hearts, static macules and static speckles of flesh and skin (i.e., subcutaneous), profuse menstruation or flooding and leaking in women, concretions and accumulations in the abdominal cavity, pale dark lips and tongue, and a fine and weak or choppy pulse. Qing Du Yin and Yang Zheng Pian were administered to all patients. Qing Du Yin consisted of the following ingredients: Paris Petiolata (Chong Lou) 8, 20g, Herba Oldenlandiae Diffusae (Bai Hua She She Cao), 30g, Rhizoma Picrorrhizae (Hu Huang Lian), Folium Daqingye (Da Qing Ye), and Bulbus Shancigu (Shan Ci Gu), 15g each. These medicinals were prepared into a concentrated liquid and 20mL were taken 3 times daily. Yang Zheng Pian consisted of the following medicinals: Radix Astragali Membranacei (Huang Qi), Herba Ecliptae Prostratae (Han Lian Cao), 30g each, Radix Panacis Ginseng (Ren Shen), 12g, Fructus Ligustri Lucidi (Nu Zhen Zi), 15g, and cooked Radix Rehmanniae (Shu Di), 20g. These medicinals were prepared into tablets and six tablets were taken 3 times daily. One treatment course lasted 1 month and all patients were observed for at least 2 treatment courses before reevaluation. Because the RAEB and RAEBT patients suffered from relatively severe heat toxin and phlegm heat branch repletions, they also took 30 pellets 3 times daily of Liu Shen Wan (Six Spirits Pill). Furthermore, one patient suffering from RAEBT received chemotherapy. Both Liu Shen Wan and chemotherapy were administered to strengthen the therapeutic heat clearing effect of Qing Du Yin. All other patients received only Qing Du Yin and Yang Zheng Pian. Supporting therapies for inpatients with hemoglobin counts less than 4.5g/mL were small transfusions of whole blood or RBC concentrate; for patients with fevers above 38.5 C and signs of infections, antibiotic or antiviral Chinese medicinals were also administered. 8 Chong Lou is a medicinal that is more often applied externally for swelling damage with toxins. Even the Zhong Yao Da Ci Dian (A Great Dictionary of Chinese Medicinals) does not give a recommended dosage for internal administration.

7 The following criteria were employed in judging the treatment outcome: Clinical remission meant that all of the main symptoms were dispersed, Hgb was$ 10g/mL, WBC$ /ml, platelets$ /ml, myelopathic hematopoiesis was obviously reduced, and blast and other immature cells accounted for < 50% [sic, more likely < 5%]. Marked improvement meant that all the main symptoms were basically dispersed (at the very least reduced by 2/3 or more), bleeding symptoms improved by two degrees or more (see below), Hgb was$ 10g/mL, WBC$ /ml, platelets increased, myelopathic hematopoiesis reduced, and blast and other immature cells accounted for < 5% [sic, more likely < 50%]. Some effect meant that all the main symptoms were reduced by at least 1/3 or more, bleeding symptoms improved by one degrees or more, Hgb increased by$ 3g/mL in comparison to prior to treatment, and blast and immature cells were reduced in comparison to prior to treatment. To further evaluate the patients progress, the six main clinical signs were divided into three stages of severity (stage I for slight, yielding one point and stage III for severe, yielding 3 points). These six signs were: 1) somber white and lackluster facial complexion, 2) fatigue and lack of strength, 3) vexing heat in the five hearts, 4) hasty breathing and shortness of breath, 5) signs of blood stasis (such as tongue signs and subdermal static macules and speckles) and 6) bleeding signs (such as dispersed subdermal bleeding for stage I, and nose, gum, menstrual, and internal organ bleeding for stage III). The results, using the above-stated criteria, were as follows: One case went into clinical remission, 5 cases improved markedly, 3 cases had some effect, and 1 case had no effect (this case was suffering from MDS- RAEBT, transformed acute leukemia and was prescribed chemotherapy; the patient eventually died of severe infections). As for life-expectancy, at the time of writing, 4 cases (3 RA and 1 RAEB) have exceeded 50 months, 3 cases (one of each RA, RAEB, and RAEBT) have exceed 18 months, and one case (RAEB) has exceeded 10 months. These patients currently remain under outpatient care and follow-up observation. One case suffering from the RAS type developed anemia after treatment; still, bleeding remained markedly better. However, four months later, he transformed RAEBT and died of severe infections. The comparison of the addition of the total points before/after treatment of the six clinical signs showed the following: somber white and lackluster facial complexion: 22/3; fatigue and lack of strength: 23/5; vexing heat in the five hearts: 12/2; hasty breathing and shortness of breath: 25/6; signs of static blood: 17/8; and signs of bleeding: 15/2 (P<0.01). Hence, all clinical signs markedly improved and the quality of life for all patients was heightened. Values of peripheral blood before and after treatment were as illustrated in Table 1: Before Treatment After Treatment P value Hgb (g/ml) ± ± 0.98 <0.01 WBC ( 10 3 /ml) 2.29 ± ± 0.34 <0.05 Platelets ( 10 3 /ml) ± ± >0.05 Table 1: Peripheral blood values before and after treatment Furthermore, comparison of dysplasia in the bone marrow as well as counts of the immature cells in the blood showed a marked improvement of these factors after treatment. The use of blood transfusions also markedly decreased. The degree of improvement ranged from no blood

8 transfusion at all in certain patients to a marked decrease of the transfusion frequency, such as a decrease from daily transfusions to monthly or even bi-monthly transfusions. Discussion Currently, the Chinese as well as the Western medical theories on the treatment of MDS are not fully developed and reports on the Chinese medical treatment of MDS are relatively rare. Western medical treatments (most commonly employing cell differentiation-inducing medication, prednisone and cortisone, or chemotherapy) yield limited effects and are accompanied by severe side-effects. MDS belongs to the traditional Chinese medical disease categories of vacuity taxation (xu lao), bleeding conditions (xue zheng), warm diseases (wen bing), cold damage (shang han), accumulations and gatherings (ji ju), and scrofula (luo li). The three factors of constitution, life circumstances, and diseases play a combined role in its arisal. Hence, this disease may be due to natural endowment insufficiency with repeated taxation of the heart and kidneys, loss of regulation of food, drink and medication with engenderment of damp toxins internally, excessive taxation fatigue [i.e., stirring] with damage to the spleen and kidneys, or a severe disease or warm [i.e., febrile] disease wearing and damaging qi and yin. Often, the arisal of MDS is due to a mixture of these above disease causes, thus leading to depletion detriment of the spleen and kidneys, insufficiency of qi and blood, internal lodging of static blood and obstruction of phlegm turbidity, and repeated contraction of external evils with subsequent internal exuberance of heat toxin. Therefore, this condition is a mixture of vacuity and repletion. Conclusion Information on MDS is very scant in the Chinese medical literature. Yet, it is a disease not too rarely seen in clinical practice. Here in the West, because there is no Western medical therapy to cure or promise to cure this disease, patients are quick to look for other treatment methods, including Chinese medicine. Following the standards of professional Chinese medicine, the Chinese medical practitioner treating a patient suffering from MDS does not need to treat the Western disease but rather determine the traditional Chinese disease category, such as taxation fatigue, accumulation and conglomeration, heat taxation, etc., and then discriminate the pattern at hand. Above, in a translation of the first textbook discussion of MDS, I have outlined the current Chinese medical standards of care in the PRC for the treatment based on pattern discrimination of MDS. However, it is important for clinical success that the corresponding formulas are modified to a) fit the exact presentation of the patient and b) include appropriate medicinals which have been shown, through clinical trials, to be effective in the treatment of MDS. This second issue is partially addressed by the above translation of a clinical audit with relatively promising treatment results for MDS patients. However, although the above clinical audit found Chinese medicine an effective method in the treatment of MDS, it also points out that the success of treatment largely depends on the stage of MDS the patients present with. RA, RAS, and RAEB seem overall easier to treat than RAEBT and seem to respond better and faster to treatment. Clinically, the early stages of MDS (particularly the two subtypes RA and RAS) often present with a more pronounced vacuity condition, such as spleen and stomach depletion or qi and blood vacuity. However, vacuity can easily lead to the accumulation of static blood and phlegm dampness which then may transform heat. Similarly, if qi and blood are weak and vacuous, defensive is depleted and external evils can easily invade. Hence, the later and more severe stages of MDS as well as the acute leukemia which may transform are clinically often characterized by vacuity conditions complicated with relatively severe repletion evils. Vacuity and repletion then perpetuate themselves in a vicious cycle and thus make the disease more difficult to treat.

9 Still, Chinese medicine seems to offer some hope to patients suffering from MDS. As Drs. Yang Hongyong et al. pointed out in the conclusion to their research paper: Considering the fact that there is not yet an effective treatment in Western medicine, the trial of using Chinese medicinals in the treatment [of MDS] promises extensive [i.e., great] prospects. 9 9 Yang Hong-yong et al., p. 25.