Professor Zhao Shaoqin on TCM Treatment and Care of Stomach Pain

Professor Zhao Shaoqin (deceased) was a lifelong professor at Beijing University of Chinese Medicine, a famous contemporary TCM physician and educator, and a master of warm-disease studies. Professor Zhao was born into a family of three generations of imperial physicians; his father Zhao Wenkui was the medical director (highest official) of the Qing imperial medical academy. Professor Zhao not only inherited his family's learning from childhood but also studied under three eminent Beijing physicians—Wang Fengchun, Han Yizhai, and Qu Wenlou—making him a true synthesizer of TCM. Professor Zhao used light, economical herbs with striking results, both inexpensive and immediately effective, and can be regarded as a model in the medical world.

Professor Zhao believed that epigastric pain must first be distinguished as stomach pain versus angina pectoris, because the epigastrium lies in the upper abdomen near the heart pit and the two are very close on the body surface, easily confused. Angina pectoris is an acute, critical condition; if resuscitation is not timely, it endangers the patient's life. Epigastric pain is generally caused by acute or chronic gastritis, gastric ulcer, duodenal ulcer, gastric neurosis, or gastric cancer—these are chronic conditions not immediately life-threatening.

Generally, stomach pain is often accompanied by "fullness or distension, vomiting and acid regurgitation, inability to eat, difficult bowel movement, diarrhea, sallow puffy face, and tired limbs," while angina pectoris is often accompanied by "hands and feet turning blue to the joints, severe heart pain, dying by evening if it arises in the morning, or dying by morning if it arises in the evening." Angina is a disease of the chest, not the stomach; it presents as a sudden, severe, knife-like pain piercing the chest and back, with palpitations and oppression when it attacks, rapid onset, and sometimes sweating and syncope, and the patient often feels a sense of impending death. Angina often occurs after overexertion. Stomach pain generally has a good prognosis, comes on gently, and is closely related to improper diet.

So epigastric pain is a stomach pain caused by digestive organs, accompanied by a series of digestive symptoms, whereas angina pectoris comes with accompanying signs such as prominent veins. The two must be distinguished; angina requires immediate hospital resuscitation.

Epigastric pain is a tormenting condition; many patients have chronic stomach pain that does not improve despite long treatment, and some gradually turn into gastric cancer. Today, stomach pain is common among urban white-collar workers, closely related to irregular routines, excessive work pressure, and too many late nights. Among the young gastric cancer patients I have encountered in recent years, many developed from stomach pain. The most regrettable was a female student studying in Canada; to rush a paper, she pushed through late nights, enduring stomach pain, until one day she suddenly found she had gastric cancer.

Chronic stomach pain, or epigastric pain, does respond to some Western treatments, but there are not many lasting, effective Western regimens. TCM has clear advantages in treating stomach pain.

Stomach pain patients should care well for their stomach both during and after treatment, while strengthening exercise—moving more to promote gastrointestinal motility—to prevent recurrence.

Professor Zhao Shaoqin summarized the causes and mechanisms of stomach disease into three points:

The first is improper diet: excessive raw/cold food or excessive rich, sweet food can all cause cold to accumulate in the middle, damp-heat to engender internally, or food to remain undigested; all can obstruct the flow of qi and produce pain and distension (incidentally, when treating digestive tract diseases—of the stomach, liver, intestines, and mouth—Professor Zhao greatly liked to spread and regulate the patient's qi flow so that the zang-fu organs pass freely and the triple burner has no obstruction. I once applied Professor Zhao's therapeutic thought to treat some gastric and liver cancer patients, with ideal results). Cold evil may also directly attack the stomach and intestines. So stomach disease truly is a disease that enters through the mouth; many stomach patients simply cannot control what they eat—raw and cold foods, grilled food, greasy food, spicy food, hotpot, and so on are all important causes. During and after treatment, stomach patients should restrain their diet, favor easily digested foods, and take appropriate exercise after meals to help gastrointestinal motility and absorption and promote gastric emptying.

The second is liver-stomach disharmony: the seven emotions bind, the liver wood fails to spread and regulate, and it assaults the stomach transversely, so that qi flow is obstructed and pain arises. The stomach is an emotional organ; a bad mood can cause gastric ulcers and other diseases. So a person who is overly depressed easily develops stomach problems. The Huangdi Neijing says: "When wood depression arises... the people suffer epigastric pain near the heart." A liver wood in excess can affect the epigastrium and cause pain. The Zazhong Yuanliu Xizhu says: "Stomach pain is a disease of evil attacking the epigastrium... the liver-qi assault is especially severe, for wood is violent and directly overacts." Patients with liver-qi depression who develop stomach disease often have a long-drawn, hard-to-heal course.

The third is spleen-stomach cold deficiency. This pattern is mostly seen in people with weak spleen and stomach or in those long ill and overworked. Spleen yang fails to rise and the stomach vessels lose warmth; or wind-cold is contracted and raw/cold food eaten, so that internal and external evil combine, cold binds internally, and the vessels congeal and stagnate—all can cause stomach pain. In replete-cold types, pain often bursts on suddenly.

Though there are three causes of stomach pain, the essential point is obstruction of qi flow and disharmony of the vessels. So when treating stomach disease, Professor Zhao first emphasized regulating qi flow, commonly using Perilla leaf (Zisuye), Perilla stem (Zisugeng), and Cyperus (Xiangfu) to spread and regulate qi and resolve disorder of upbearing and downbearing. TCM has always held that "if it is free, there is no pain; if there is pain, it is not free." So Professor Zhao believed stomach pain should be treated primarily by unblocking, with cautious use of tonification; but for some patients whose disease arises from deficiency, one should not be rigidly bound by the old maxim "tonification has no place in pain."

Based on the causes of epigastric pain, Professor Zhao set out treatment principles.

I. Binding of the Seven Emotions

Stomach pain caused by binding of the seven emotions is fairly common clinically. We often say anger "explodes the lungs," and we also say anger causes stomach pain; excessive anger or sadness indeed readily causes gastric spasm and pain. The idiom "indignation fills the breast" describes the gastric fullness and discomfort that follow anger, resentment, brooding, and anxiety. Such patients have liver-qi depression and disordered, unreached qi flow; treatment focuses mainly on regulating qi.

Formula: Modified Seven Qi Decoction (Siqi Tang): Perilla leaf (Zisuye) 6 g, Perilla stem (Zisugeng) 6 g, Pinellia (Banxia) 10 g, Tangerine peel (Chenpi) 6 g, Cyperus (Xiangfu) 10 g.

This formula is Pinellia-Magnolia Decoction (Banxia Houpo Tang) with added Jujube; it moves qi and opens stagnation, and downbears counterflow and resolves phlegm. Pinellia resolves phlegm and opens bind, harmonizes the stomach and downbears counterflow; Tangerine peel is aromatic and warm, regulating qi and moving the spleen, harmonizing the middle and quickening the diaphragm; Perilla leaf and stem course qi and loosen the chest, spreading bound qi; Cyperus soothes the liver and resolves depression, regulates qi flow and stops pain.

For severe pain, Mu xiang (costus), Corydalis (Yanhusuo), Melia (Chuanlianzi), and Aurantium (Zhiqiao) may be added as appropriate to enhance qi regulation, depression resolution, and pain relief. For frequent belching, Chenxiang (Aquilaria) and Inula (Xuanfuhua) may be added to course qi and downbear counterflow.

Zhiyuan's note: For this type of patient, the patent medicine Shugan Hewei Pills also work very well. Shugan Hewei Pills are mainly composed of Cyperus (Xiangfu), White Peony (Baishao), Finger Citron (Foshou), costus (Muxiang), Curcuma aromatica (Yujin), stir-fried Atractylodes (Chao Baizhu), Tangerine peel (Chenpi), Bupleurum (Chaihu), Agastache (Huoxiang), honey-fried Licorice (Zhi Gancao), Raphanus seed (Laifuzi), scorched Areca (Jiao Binglang), and Lindera (Wuyao); they move qi and stop pain, strengthen the spleen and regulate qi, and resolve depression and disperse nodules.

II. Liver-Stomach Stagnant Heat

Patients of this type generally have qi depression that has bound and transformed into fire over a long time, so the epigastrium has burning pain with urgent onset; they are irritable and prone to anger, sometimes with acid regurgitation and gnawing hunger, dry mouth and bitter mouth, a yellow greasy tongue coating, and even mouth and tongue ulcers; the pulse is generally wiry or rapid. Such patients have often progressed to gastric or duodenal ulcer, with pain triggered by the ulcer site.

Treatment: bitter-springing to drain heat; soothe the liver and harmonize the stomach.

Formula: Modified Left Golden Pill (Zuojin Wan).

Formula 1: Perilla stem (Zisugeng) 10 g, Inula (Xuanfuhua) 10 g, Pinellia leaven (Banxiaqu) 10 g, Cyperus (Xiangfu) 10 g, Thalictrum (Maweilian) 10 g, Evodia (Wuzhuyu) 1.5 g, Melia (Chuanlianzi) 10 g.

Formula 2: Melia (Chuanlianzi) 12 g, Thalictrum (Maweilian) 10 g, Evodia (Wuzhuyu) 1.5 g, Corydalis (Yanhusuo) 6 g (ground and taken separately), Cyperus (Xiangfu) 10 g, Trogopterus (Wulingzhi) 10 g, Scutellaria (Huangqin) 10 g, Bupleurum (Chaihu) 6 g.

Left Golden Pill is made of Coptis (Huanglian) and Evodia (Wuzhuyu); here Professor Zhao replaces Coptis with Thalictrum (Maweilian, also called Maweihuanglian), a habit of his. Maweihuanglian's action is similar to Coptis, but its bitter-cold nature is less severe, so it does not so easily damage the patient's spleen and stomach.

Modifications:

1. For severe epigastric burning pain, gnawing hunger, and acid regurgitation, combine Left Golden Pill with Moutan-Gardenia Free-and-Easy Wanderer Powder (Danzhi Xiaoyao San), minus Atractylodes and Ginger.

2. For liver fire damaging yin, add unprocessed Rehmannia (Shengdi) and Moutan (Danpi), or use One-Wire Decoction (Yiguan Jian), to also treat dry throat and mouth, a red tongue with little moisture, and a thin rapid or deficient wiry pulse.

3. With accompanying irritability, many dreams, a wiry pulse, and a dry tongue, combining Left Golden Pill with Golden Bell Powder (Jinlingzi San) suffices.

Zhiyuan's note: Treating this type of patient with integrated Chinese-Western medicine works faster and more markedly. Burning epigastric pain caused by acute gastric or duodenal ulcer is generally easy to treat. But in chronic patients the ulcer opening is hard to heal; one should consider giving the patient zinc supplementation, because zinc helps the ulcer close quickly and can also prevent recurrence, so such patients should consider long-term zinc supplementation after recovery.

On the harms caused by zinc deficiency, I have written an article: The Harms of Zinc Deficiency—click the bold link to read it.

III. Stomach Pain with Yin Damage

Professor Zhao believed that long-standing stomach pain, for various reasons, causes stomach fluids to wither and stagnant fire to exuberate internally; the patient has dry mouth and throat, thirst, dry stools, a red tongue with little moisture as fire scorches stomach yin, and a mostly thin wiry pulse.

For this type of patient, Professor Zhao's treatment principle was to harmonize the yin aspect and discharge the accumulated heat.

Formula: Modified One-Wire Decoction (Yiguan Jian): Glehnia/Adenophora (Shashen) 12 g, Melia (Chuanlianzi) 12 g, Ophiopogon (Maidong) 10 g, raw Cyperus (Sheng Xiangfu) 10 g, stir-fried Trogopterus (Chao Wulingzhi) 12 g, raw Typha pollen (Sheng Puhuang, wrapped in cloth) 10 g, raw White Peony (Sheng Baishao) 12 g, Evodia (Wuzhuyu) 1.5 g, Thalictrum (Maweilian) 10 g.

Here, One-Wire Decoction is good at nourishing yin and softening the liver, and soothing the liver and regulating qi. This formula combines Left Golden Pill and Smile-Stopping Powder (Shixiao San) with modifications.

Modifications:

1. For dry mouth and throat with vexing thirst.