Qin Changyu on the Treatment of Stomach Epigastric Pain

Doctor zhou
The Ming-dynasty physician Qin Changyu (courtesy name Jingming), in his work Bing Yin Mai Zhi (Treatment of Disease According to Cause, Symptom and Pulse; for an introduction to Qin Changyu and his works see my article The Late-Ming TCM Master Qin Jingming and His Work Bing Yin Mai Zhi), has a dedicated chapter titled Weitong Zheng Yin Mai Zhi, discussing how epigastric pain should be treated.
In this chapter, Qin Changyu first distinguished epigastric pain from pericardial channel pain (i.e. what modern medicine calls angina pectoris), because the location of the pain in the two is very similar and they are easily confused. Qin Changyu said: Generally, pain with ability to eat and drink is pericardial-channel pain; pain without ability to eat and drink is epigastric pain. This method of distinction is fairly scientific: angina pectoris does not affect appetite, while epigastric pain does.
Qin Changyu then divided epigastric pain into exterior-contraction epigastric pain (caused by wind-cold or summerheat) and internal-injury epigastric pain. This classification is also very scientific: exterior-contraction epigastric pain mostly belongs to acute gastrointestinal disease, while internal-injury epigastric pain mostly belongs to chronic stomach disease.
Qin Changyu held: When there has never been this condition, and one happens to encounter abrupt seasonal cold, with pain below the heart, aversion to cold and cold limbs, clear urination and stool, and vomiting of cold froth, this is cold evil entering the stomach, congealing phlegm-fluid and food stagnation, a sudden acute pain pattern. If the season is suddenly hot and there is sudden colicky pain below the heart; although the hands and feet are cold, there is sweating on the forehead; although the body has aversion to cold, the mouth is parched and tongue dry; although the stool is diarrheic, the urine is yellowish-red; this is a pattern of injury by damp-heat.
Qin Changyu further pointed out the cause of exterior-contraction epigastric pain: The person central qi has long been cold, and upon accidental contact with seasonal cold, cold congeals at the stomach opening and causes pain. If there is internal accumulated heat and externally one contacts damp-heat, the two heats steam and ferment, heat congests the stomach opening and also produces stomach pain. The pulse in exterior-contraction epigastric pain may be floating and tight (cold evil in the exterior), or deep and wiry (cold evil entering the interior), or floating and rapid (heat evil in the exterior), or deep and rapid (heat binding in the interior).
The exterior-contraction epigastric pain summarized by Qin Changyu roughly corresponds today to acute gastroenteritis caused by viral or bacterial infection. When the weather is extremely cold or hot, viruses and bacteria run rampant and human immunity is low; after infection with pathogens, one easily develops digestive symptoms, stomach pain, and sometimes even diarrhea, with or without fever. This kind of epigastric pain is an acute disease and should follow the principles for treating acute disease.
Qin divided this acute epigastric pain into two types, cold pain and heat pain. For cold pain, Wuji San is used to treat both exterior and interior, both eliminating internal pain and dispersing wind-cold; after wind-cold is dispersed, Wenwei Tang is used to regulate. For heat pain, Shenshu Pingwei San is used to clear external heat, and then Qingzhong Tang to clear internal heat.
Wuji San consists of Bafuling (White Poria), Chenpi (Tangerine peel), Banxia (Pinellia), Gancao (Licorice), Chuanxiong (Ligusticum), Baizhi (Angelica dahurica), Zhiqiao (Immature Bitter Orange), Houpo (Magnolia bark), Cangzhu (Atractylodes), Mahuang (Ephedra), Ganjiang (Dried Ginger), Rougui (Cinnamon bark), and Jiegeng (Platycodon).
Wenwei Tang consists of Houpo (Magnolia bark), Sharen (Amomum), Gancao, Chenpi, Ganjiang (Dried Ginger), Baidoukou (White Cardamom), Huangqi (Astragalus), Renshen (Ginseng), Jianghuang (Turmeric), and Yizhiren (Alpinia oxyphylla).
Shenshu Pingwei San consists of Cangzhu (Atractylodes), Fangfeng (Saposhnikovia), Gancao, Shigao (Gypsum), Zhimu (Anemarrhena), Houpo (Magnolia bark), and Chenpi.
Qingzhong Tang consists of Huanglian (Coptis), Shanzhizi (Gardenia), Caodoukou (Katsumadai), Banxia, Chenpi, Bafuling, and Gancao.
Qin prescriptions did not note dosages, intending that the physician decide the dosage according to the patient condition.
In my experience, Wuji San and Qingwei Tang are more suitable for epigastric pain caused by viral infection, while Shenshu Pingwei San and Qingzhong Tang are more suitable for epigastric pain caused by bacterial infection; Qingzhong Tang in particular is a formula based on Huanglian and Zhizi, and berberine is the main drug for bacterial gastroenteritis.
Qin Changyu then categorized internal-injury epigastric pain. The overall characteristic of internal-injury epigastric pain is that the patient is not caused by exterior contraction of the six excesses, but has a chronic disease. Internal-injury epigastric pain is further divided into seven types: food accumulation pattern, phlegm-fluid pain, accumulated-heat pain, accumulated-cold pain, qi-stagnation pain, dead-blood pain, and worm-accumulation pain.
The characteristic of food-accumulation pain is occasional injury by diet causing chest oppression pain, which even radiates to the back; food-accumulation pain should be treated with Sanleng Wan.
Sanleng Wan formula: Sanleng (Sparganium), Zhiqiao (Immature Bitter Orange), Houpo (Magnolia bark), Chenpi, Gancao.
The characteristic of phlegm-fluid pain is pain with phlegm, mostly because the spleen and stomach are naturally weak, and daily intake of water and grain cannot be transformed and received, stagnating in the middle burner and gradually forming phlegm-fluid. Phlegm-fluid pain is treated with Erchen Tang and Daotan Tang; in severe cases, Guntan Wan may be used.
Erchen Tang formula: Banxia, Fuling, Juhong (Tangerine red), Zhigancao (honey-fried Licorice), Wumei (Mume). The patent medicine Erchen Wan is made according to the Erchen Tang formula.
Daotan Tang formula: Banxia, Juhong, Fuling, Zhishi (Immature Bitter Orange), Tiannanxing (Arisaema), Zhigancao.
Guntan Wan is the patent medicine Mengshi Guntan Wan; this is a prescription drug and can only be bought with a doctor prescription.
Accumulated-heat pain is mostly caused by exuberant fire from the seven emotions and six desires, plus eating too much rich, fatty, grilled and pickled food, so heat accumulates and produces dry fire. Patients with accumulated-heat pain have paroxysmal attacks; during attacks they are thirsty with dry lips, and sweat with pain. Accumulated-heat pain is treated with Zhilian Qingwei Tang; for those with constipation and other signs, use Shenxiong Wan. Zhilian Qingwei Tang consists of Zhizi (Gardenia), Huanglian (Coptis), Huangqin (Scutellaria), Shengdi (Raw Rehmannia), Mudanpi (Moutan bark), Danggui (Angelica), and Shengma (Cimicifuga). Shenxiong Wan consists of Dahuang (Rhubarb), Huangqin, Heiqianniuzi (black Morning Glory seed), Huashi (Talc), Bohe (Mentha), and Chuanxiong.
Accumulated-cold pain is mostly caused by insufficient stomach yang, with internal injury by cold drinks, leading to congelation of yin-cold. Patients with accumulated-cold pain have clear urination and stool, cold hands and feet, vomiting of salivary froth, and worsening with cold drinks. This kind of epigastric pain is treated with Doukou Wan, consisting of Caodoukou (Katsumadai), Wuzhuyu (Evodia), Yizhiren (Alpinia oxyphylla), Qingpi (Green Tangerine peel), Jianghuang (Turmeric), Maiya (Barley sprout), Shenqu (Medicated Leaven), Banxia, and Gancao.
Qi-stagnation pain is mostly caused by patients who are naturally prone to anger or to much anxiety and pensiveness; anger and anxiety both easily cause disordered qi movement, and over time this brews into qi-stagnation type epigastric pain. Qi-stagnation pain is treated with Suzi Jiangqi Tang, consisting of Zisuzi (Perilla seed), Banxia, Danggui, Gancao, Qianhu (Peucedanum), Houpo (Magnolia bark), and Rougui (Cinnamon bark).
The characteristic of dead-blood pain is that it is triggered by qi, attacks and moves about, is lighter by day and heavier by night; the patient moans and groans with pain, worsens with cold and is temporarily eased by warmth. This is because the patient blood portion is naturally hot and also likes pungent-hot foods, so yin blood is damaged, stagnating in the center; over time this becomes dead-blood pain.
Dead-blood pain with a mass on pressing the epigastrium, and pain that frequently attacks without ceasing, mostly belongs to gastric cancer in modern medicine; TCM calls it pi-ji (stagnation) accumulation pain. The medicine Qin Changyu recommended was his family-prescription Xiaojian San (consisting of Sanleng (Sparganium), Ezhu (Curcuma), Binglang (Areca), Zhishi (Immature Bitter Orange), Xiangfu (Cyperus), and Haifushi (pumice stone)). If the pi accumulation is in the upper part, add Cangzhu (Atractylodes) and Houpo (Magnolia bark) to Xiaojian San; if in the lower part, add Qingpi (Green Tangerine peel) and Zhiqiao.
If the pain worsens at night or with cold, there is resistance on pressing the abdomen, or food entering the stomach can only pass down one side, this is also pain caused by blood stasis; this may be cardia cancer in modern medicine. Such patients are first treated with Sanleng Wan, and later with Taoren Chengqi Tang or Honghua Taoren Tang.
Sanleng Wan formula: Sanleng (Sparganium), Zhiqiao (Immature Bitter Orange), Houpo (Magnolia bark), Chenpi, Gancao.
Tao Ren Chengqi Tang: Taoren (Peach kernel), Gancao, Mangxiao (Mirabilite), Dahuang (Rhubarb).
Honghua Taoren Tang: Honghua (Safflower), Taoren (Peach kernel), Guiwei (Angelica tail), Chishao (Red Peony), Zelanye (Lycopus), Shanzha (Hawthorn flesh), Danpi (Moutan bark), Zhizi (Gardenia).
Worm-accumulation pain is mostly caused by parasites; patients often vomit clear fluid, have white spots on the face, red lips and good appetite, and sometimes even spit out roundworms. Such diseases are now rare; Qin Changyu treated worm accumulation universally with Wanying Wan.
Wanying Wan formula: Maiya (Barley sprout), Shenqu (Medicated Leaven), Leiwan (Omphalia), Chenpi, Gancao, Sanleng (Sparganium), Ezhu (Curcuma), Binglang (Areca), Wuyi (Ulmus macrocarpa), Heshi (Carpesium), and Shijunzi (Quisqualis). Many herbs in this formula have anthelmintic action but are also toxic; today they are mostly replaced with modern anthelmintics.
In addition, Qin had the family-prescription Baohe San, specifically treating pain immediately upon eating, with frequent belching; this belongs to epigastric pain caused by indigestion. Baohe San formula: Cangzhu (Atractylodes), Houpo (Magnolia bark), Banxia, Chenpi, Zhiqiao, Maiya, Shanzha (Hawthorn flesh), Xiangfu (Cyperus), Binglang (Areca), Gange (Kudzu root), Laifuzi (Radish seed), ground together into fine powder; blend with much radish juice and Zhuli (bamboo sap), moisten, dry in the sun, grind into fine powder, and take with plain water.

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