The experiences of Zheng-ping Bai in treating gastric cancer based on qi, phlegm,and stasis

Xiao-yan Cheng, Zheng-ping Bai

1Hunan Academy of Traditional Chinese Medicine Affiliated Hospital, Changsha,China;2Hunan Academy of Traditional Chinese Medicine, Changsha, China.

Abstract This paper will introduce the clinical experiences of Professor Zheng-pingBai in treating gastric cancer.In his diagnosis and treatment of this disease, Professor Bai advocates the integration of disease, symptom, and syndrome differentiation, pointing out that gastric cancer is caused by the accumulation of phlegm-dampness and blood stasis in the stomach due to qi stagnation.Therefore, the basic pathogenic mechanism involves the loss of harmonious descent in the stomach.This implies that treatment should prioritize qi activity by calming the stomach and suppressing the abnormal ascent of qi, as well as emphasizing the elimination of phlegm and stasis,and this has achieved significant therapeutic efficacy.

Keywords: gastric cancer; experiences of famous doctors; qi activity; phlegm and stasis.

Introduction

Professor Bai Zhengping is part of the sixth batch of national instructors for the inheritance of famous old doctors of traditional Chinese medicine (TCM).He is also a professor (Level 2), chief physician (Level 1),Ph.D.supervisor, an eminent TCM physician in Hunan,and an expert who is granted the Special Government Allowance by the State Council.He has engaged in clinical work for nearly 40 years and is proficient in the application of TCM in the prevention and treatment of malignant tumors and respiratory diseases.Gastric cancer is a type of cancerous disease caused by the inner deficiency of healthy qi, as well as improper diet and emotional disorders.Its main presentations include abdominal bloating or pain, poor appetite and digestion, weight loss, melena, abdominal masses, and recurrent vomiting.Due to changes in diet structure,greater work stress, Helicobacter pylori infection, and various other reasons, there is currently a trend towards the occurrence of gastric cancer in younger patients.In the course of his clinical diagnosis and treatment,Professor Bai Zhengping employed etiological and pathogenic analysis, together with the integration of disease, symptom, and syndrome differentiation, to give TCM prescriptions and flexibly implement addition and subtraction based on qi, phlegm, and stasis.His methods have resulted in the attainment of significant clinical efficacy.As I have had the fortune of studying under Professor Bai Zhengping, I present a summary of his clinical ideas for the treatment of gastric cancer,together with my own learning experiences.

1 Disease differentiation based on qi, phlegm, and stasis

1.1 Mutual obstruction of phlegm and qi, and the coagulation and stagnation of phlegm-dampness in the early stage:

Improper diet or excessive intake of raw or cold food can damage the Yang qi of the spleen and stomach, thus preventing the warming of retained fluids.Since the stomach and spleen are exteriorly-interiorly related, the spleen governs the movement of gastric fluids, and the loss of healthy spleen function gives rise to dampness and phlegm, ultimately obstructing the stomach and bowels [1].Emotional disorders, such as anxiety leading to spleen injury, or anger leading to liver injury,can cause the stagnation of liver-qi and oppression of spleen-earth, leading to spleen injury, Qi stagnation,and retention of water-dampness.The persistence of this condition gives rise to the accumulation of frustrations and generation of heat, followed by the transformation of the resulting stagnant fire into toxins that enter the collaterals, thus causing disharmony between the liver and stomach, and gradually damaging the spleen and stomach.This ultimately leads to the congestion of stasis and toxins in the stomach, the dysregulation of gastric harmonious descent, and qi stagnation in the spleen and stomach [2].

1.2 Intermingling of phlegm and stasis to form masses in the intermediate stage

This condition mostly results from liver-qi stagnation caused by emotional disorders, which leads to the dysregulation and stagnation of qi activity.In turn,the lack of qi movement leads to blood stagnation and stasis formation, which becomes entangled with gastric phlegm-dampness over time, whereas the intermingling of phlegm and stasis eventually leads to the formation of masses.Gastric qi tends to descend and must remain unobstructed to function properly, whereas the harmonious descent of gastric qi is dependent on the smooth flow of liver qi.The loss of smooth liver function leads to the loss of the harmonious descent of gastric qi, which may lead to qi stagnation and blood stasis, eventually leading to the formation of masses.

1.3 Deficiency of healthy qi and widespread deterioration in the late stages

Among patients with an inner deficiency of healthy qi presenting with symptoms such as gastric pain and distention, those with long-term refractory disease,weak constitution due to old age, or those who have received no treatment or the wrong treatment,eventually experience the loss of human qi and Yang qi, qi deficiency and the inability to mobilize blood circulation, as well as the stagnation of qi and blood.In addition, patients develop dysregulation of the spleen and stomach, lack of sources for the production and transformation of qi and blood, and the inadequacy of healthy qi to guard against external pathogens,thus causing the buildup of phlegm and stasis, and giving rise to gastric cancer.The long-term inability to remove pathogenic blood and failure to produce new blood eventually causes the formation of abdominal masses and aggravates the disease.At this point, the patient experiences the severe depletion of qi and blood, the dysregulation of the spleen and stomach, and the intermingling of phlegm and stasis, thus forming the syndrome of Deficiency in Origin and Excess in Superficiality (Benxu Biaoshi).

2 Focus on the regulation of qi activity

The pathogenesis of gastric cancer tends to be relatively slow.Patients in the earlier stages may be completely asymptomatic, or their initial symptoms may include gastric pain, belching and bloating, poor appetite, and melena.Although the disease is located in the stomach,it is closely related to organs such as the liver, spleen,and kidney.The meridians of the liver, spleen, and kidney all circulate through the stomach.Furthermore,the stomach and spleen are exteriorly-interiorly related.Hence, the spleen governs the movement of gastric fluids, and the loss of healthy spleen function gives rise to dampness and phlegm, ultimately obstructing the stomach and bowels.In addition, gastric qi has a tendency to descend and must remain unobstructed to function properly, whereas the harmonious descent of gastric qi is dependent on the smooth flow of liver Qi.The loss of smooth liver function leads to the loss of the harmonious descent of gastric qi, which may lead to qi stagnation and blood stasis, eventually leading to the formation of masses [3].The middle burner,spleen, and stomach all depend on the nourishment and warmth from the primal Yin and primal Yang of the kidneys.The insufficiency of kidney Yin can lead to the loss of nourishment and the insufficiency of gastric Yin, whereas the loss of gastric moisture may lead to gastric cancer.The insufficiency of kidney Yin can also lead to the loss of warmth in the spleen and stomach,causing the inner generation of deficient coldness,whereas the lack of Yang qi entails the inability to transform qi and circulate water, thus giving rise to the rapid deterioration in qi stagnation, phlegm obstruction,and blood stasis.The early stage is characterized by the mutual obstruction of phlegm and qi, as well as the coagulation and stagnation of phlegm-dampness, which is predominantly excess in superficiality.Over time, the disease evolves into deficiency in origin and excess in superficiality, wherein the deficiency in origin mainly involves the depletion of gastric Yin and the deficient coldness of the spleen and stomach, whereas the excess in superficiality mostly involves the intermingling of phlegm and stasis [4].Therefore, treatment of this disease must prioritize the regulation of qi activity.

3 Treatment should focus on removing phlegm and resolving stasis

Phlegm and stasis are special types of toxic pathogens,and the toxins resulting from the intermingling of phlegm and stasis are key to the pathogenesis of gastric cancer.InSu Wen: Tongping Xushi Lun (Basic Questions: General Treatise on Vacuity and Repletion),it is stated that "A thing that can harm humans is known as a toxin." Hua Tuo writes inZhong Zang Jing: Lun Yongju Chuangzhong Di Sishiyi (Classic of the Central Viscera: On Ulcers, Abscesses, Sores and Swellings, Chapter 41) that "Ulcers, abscesses,sores, and swellings are all caused by the accumulation and stagnation of toxins in the five solid organs and six hollow organs, not solely due to the congestion of nutrient and defensive qi." Furthermore, it is written in theShengji Zonglu(Complete Record of Sacred Benevolence) that "The meaning of tumor is stagnation without movement." Therefore, the pathogenesis of this disease is related to the deficiency of healthy qi and the invasion of pathogenic toxins.

Based on his many years of clinical experience,Professor Bai has implemented the formulation of TCM prescriptions based on qi, phlegm, and stasis.The basic prescription is as follows: Dangshen (Radix Codonopsis) 10 g, Wuyao (Radix Linderae)10 g, Bai zhu(Rhizoma Atractylodis Macrocephalae)10 g, Shi jianchuan (Herba Salviae Chinensis)10 g, Banzhi lian (Herba Scutellariae Barbatae)15 g ,Chonglou(Rhizoma Paridis) 5 g , Sheshe Cao (Herba Hedyotis Diffusae)15 g, Zhiqiao (Fructus Aurantii)10 g, Hou pu (Cortex Magnoliae Officinalis)10 g, Chenxiang(Lignum Aquilariae Resinatum)3 g, Foshou (Fructus Citri Sarcodactylis)10 g, Yujin (Radix Curcumae)10 g, Sharen (Fructus Amomi)10 g, Laifuzi (Semen Raphani)10 g, Jineijin (Endothelium Corneum Gigeriae Galli)10 g, Huang Qin (Radix Scutellariae)10 g , Pu gongying (Herba Taraxaci)10 g, Haipiaoxiao(Os Sepiae)15 g, and Gancao (Radix Glycyrrhizae)3 g .In this prescription, Dangshen (Radix Codonopsis)and Baizhu (Rhizoma Atractylodis Macrocephalae)serve to strengthen the spleen and nourish 1i; Shijian chuan (Herba Salviae Chinensis), Banzhilian (Herba Scutellariae Barbatae), Chonglou (Rhizoma Paridis),Baihua Sheshe Cao (Herba Hedyotis Diffusae) serve to clear heat, expel toxins, reduce swelling, and dissipate masses; Wuyao (Radix Linderae) and Chenxiang(Lignum Aquilariae Resinatum) serve to invigorate qi, relieve pain, warm the middle, and stop vomiting;Zhi qiao (Fructus Aurantii) and Houpu (Cortex Magnoliae Officinalis) serve to regulate qi, soothe the middle, invigorate stagnation, dispel swelling,descend qi, and eliminate bloating; Foshou(Fructus Citri Sarcodactylis) and Yujin (Radix Curcumae) serve to calm the stomach, relieve pain, soothe the liver, and regulate qi; Sharen (Fructus Amomi) serves to resolve dampness, warm the middle, and invigorate qi; Laifu Zi(Semen Raphani) and Jinei Jin (Endothelium Corneum Gigeriae Galli) serve to aid digestion, eliminate bloating, descend qi, and resolve phlegm; Huang qin (Radix Scutellariae) and Pugong Ying (Herba Taraxaci) serve to clear heat, expel dampness, purge fire, eliminate toxins, dispel swelling, and dissipate masses; Haipiaoxiao(Os Sepiae) serves to astringe and stop bleeding, as well as control acid production;and Gancao (Radix Glycyrrhizae) serves to relieve spasms and pain, and harmonize the other medicinal materials.The combination of medicinal materials in this prescription as a whole accounts for both the origin and superficiality, while also implementing purgation and tonification in equal measure.Therefore, it jointly strengthens the spleen, eliminates dampness, calms the stomach, and suppresses the abnormal ascent of qi, thereby invigorating qi, relieving pain, resolving phlegm, and dispelling stasis, ultimately achieving the function of expelling toxins and eliminating cancer.

4 Symptom-based addition and subtraction

Professor Bai noted that implementing addition and subtraction according to the variations in the patients'symptoms enables the rapid alleviation of their discomfort and enhances treatment efficacy.(1) Patients presenting with vomiting, nausea, and loss of appetite should mainly be treated by calming the stomach and suppressing the abnormal ascent of qi using medicinal materials such as Xuanfuhua (Flos Inulae), Banxia(Rhizoma Pinelliae), Chenpi (Pericarpium Citri Reticulatae), and Daizheshi (Haematitum).However,the prescription of these medicinal materials should also be based on syndrome differentiation.More specifically, vomiting with cold syndrome should be treated with Suye (Folium Perillae) and Sheng jiang(Rhizoma Zingiberis Recens); vomiting with heat syndrome should be treated with Huanglian (Rhizoma Coptidis) and Zhuru (Bambusae Caulis in Taeniam);vomiting with dampness syndrome should be treated with Huoxiang (Herba Pogostemonis) and Doukou(Fructus Amomi Rotundus); vomiting with qi deficiency should be treated with Sharen (Fructus Amomi) and Baizhu (Rhizoma Atractylodis Macrocephalae);and vomiting with Yin deficiency should be treated with Shihu (Herba Dendrobii) and Lugen (Rhizoma Phragmitis).Patients with mouth and tongue sores can be divided into two groups on the basis of their symptoms: those with mouth sores and those with tongue sores.However, in syndromes such as heat stagnation in the spleen and stomach, or excessive heart-fire, both the mouth and tongue are nourished and fumigated by gastric qi, and are subjected to pathogenic invasion at the same time.Therefore, it is generally not possible to categorically separate mouth and tongue sores.It is common for cancer patients to experience Yin deficiency and excessive heat.To address this reaction, it is often necessary to clearly differentiate between the two syndromes of Yin deficiency and excessive heat.Patients with excessive heat often present with dry stools, thirst and the desire to drink, a dirty tongue coating and a bad breath, gum ulcers, and burning pain in the oral cavity.Yinhua (Flos Lonicerae) and Huanglian (Rhizoma Coptidis) should be added for these patients to dispel heat with bitter cold and purging of the hollow organs.Patients with Yin deficiency often present with a red tongue without a coating, mouth ulcers, a dry and painful throat, and even difficulty eating.These patients should be treated with Xijiao Dihuang Decoction plus a large amount of YeJu (Flos Chrysanthemi Indici), Pugongying(Herba Taraxaci), and Zicao (Radix Lithospermi) to cool the blood and nourish Yin, in order to alleviate their symptoms.(3) Dizziness caused by qi and Yin deficiency can generally be treated with medicinal materials that nourish Yin and the blood, such as Jixue teng (Caulis Spatholobi), Danggui (Radix Angelicae Sinensis), Heshouwu (Radix Polygoni Multiflori),Nvzhenzi (Fructus Ligustri Lucidi), and Hongzao(Fructus Jujubae).Based on the conditions of the patient’s Yin, Yang, qi, and blood, they should also be given supplements for deficiencies and support of normal functions, rather than simply administering Yin- and blood-nourishing medicines.Those with qi deficiency syndrome can be treated with medicinal materials that supplement Qi, such as Huangqi (RadixAstragali) and Dangshen (Radix Codonopsis).Those with syndromes such as spleen deficiency and diarrhea can be given spleen-invigorating and anti-diarrheal medicines.Patients with both vomiting and the inability to eat should first be treated according to their symptoms with medicines that calm the stomach and suppress the abnormal ascent of qi, so as to address the loss of appetite.Otherwise, the patients will not be able to absorb the supplementary nourishments provided and will experience poor function and transformation,which hinders the objective of nourishing the blood [5].

5 Syndrome differentiation

The following are the common syndrome types in gastric cancer: (1) Liver-stomach disharmony:Symptoms include belching of sour and putrid gas,yellow tongue coating, a wiry pulse, and vomiting.Patients should be treated by soothing the liver and calming the stomach with Zhuru (Bambusae Caulis in Taeniam), Duanwaleng (Concha Arcae), and Choumu dan(Caulis et Folium Clerodendri Bungei) added to the basic prescription.(2) Intermingling of dyspeptic food with phlegm blockade: Symptoms include chest tightness, poor appetite, loose stools, a thick and greasy tongue coating, abdominal distention and reduced food intake, dislike of meat, vomiting, and sticky phlegm mixed with blood.Patients should be treated by the elimination of phlegm and indigestion with Shan Zha Tan(Fructus Crataegi Carbonisatum) and Tengligen (Radix Actinidiae Chinensis).(3)Intermingling of phlegm and stasis: Symptoms include xerostomia, bluish-purple tongue, smooth tongue coating, abdominal tenderness and discomfort with a fixed location for the pain and palpable swelling, and hematemesis or melena.Patients should be treated by blood regulation and phlegm elimination with Sanqi(Radix Notoginseng), Qingmengshi(Lapis Chloriti), and Caulis et Choumudan (Folium Clerodendri Bungei).(4) Deficiency of gastric Yin: Symptoms include gastric discomfort, a feverish sensation in the chest, palms, and soles, thirst and a desire to drink,reduced food intake and loose stools, a red dehydrated tongue, as well as abdominal distention and burning pain.Patients should be treated with the nourishment of gastric Yin using the Yangwei Decoction and the addition of Caulis et Choumudan(Folium Clerodendri Bungei).(5) Deficient coldness of the spleen and stomach: Symptoms include fatigue, cold extremities,reduced food intake and loose stools, dull abdominal pain, relief with warmth and pressure, a hard mass,vomiting, clear saliva, a white tongue coating, and a deep and slow pulse.Patients should be treated with the warming and nourishment of the spleen and stomach using Dingkou Lizhong Decoction.

For the syndromes described above, patients in the early stages or those with stable disease during the pathogenesis of gastric cancer mainly present with the syndromes of liver depression and qi stagnation,as well as liver-stomach disharmony.Patients should be treated with the medicinal materials that soothe the liver, regulate qi, and calm the stomach, based on their syndromes, in order to alleviate or eliminate their symptoms.In cases of secondary infection or progressive disease, patients often present with signs of stasis toxins and damp heat, which should be promptly treated with detoxification and blood invigoration to control infections, which ensures the gradual stabilization of the disease.In advanced or deteriorating cases, patients present with syndromes of gastric heat, Yin injury, and Yin deficiency in the liver and kidneys.The most prominent symptom at this stage is partial to complete exfoliation of the tongue coating,which should be treated with medicines that cool the blood and nourish Yin to restore the tongue coating.Remission is still possible in these cases.Syndromes of dual qi and blood deficiency, Yang-deficiency of the spleen and kidney, and deficient coldness of the spleen and stomach are mostly related to the Yang and qi deficiencies of the patient’s constitution, or the long-term use of cooling medicines.Therefore,patients often present with a white tongue or a deep-red tongue that turns light-red, along with cold extremities,reduced food intake, abdominal distension, loose stools, clear urine, and other symptoms.These patients should receive qi nourishment, Yang invigoration, and regulation of the spleen and stomach.

6 Typical case study

A male patient (Wang) aged 75 years was admitted to our hospital for treatment in July 2020.The patient had sought treatment elsewhere two months prior to admission due to a sensation of obstruction when eating.Gastroscopy indicated cancer of the gastric cardia; pathological findings indicated poorly differentiated adenocarcinoma.The patient had an impatient temperament.The patient’s family members refused surgical treatment and chemoradiotherapy due to his advanced age and hence visited our hospital to seek TCM treatment.Current symptoms: gastric obstruction after eating, bloating, mild distending pain in the hypochondrium, hiccups, nausea, with relief after flatulence.The patient was able to sleep and urinate,and had yellow formed stools.The patient’s tongue was deep red in color with a thin, yellow greasy coating,and a fine, wiry pulse.Diagnosis: Cancer of the gastric cardia.Prescription: addition and substruction of the gastric cancer prescription: Dangshen (Radix Codonopsis)10 g, Wuyao (Radix Linderae)10 g , Bai zhu (Rhizoma Atractylodis Macrocephalae)10 g , Shi jianchuan (Herba Salviae Chinensis)10 g, Banzhi lian (Herba Scutellariae Barbatae)15 g, Chonglou(Rhizoma Paridis)5 g, Sheshecao (Herba Hedyotis Diffusae)15 g, Yujin (Radix Curcumae)10 g, Tufu ling (Rhizoma Smilacis Glabrae)15 g, Yangkaikou(Akebia puinata)10 g, Shancigu(Rhizoma Pleionis)10 g, Dafupi (Pericarpium Arecae)10 g, Sharen (Fructus Amomi)5 g, Chenpi (Pericarpium Citri Reticulatae)10 g, Jinei jin (Endothelium Corneum Gigeriae Galli)10 g, Shan zha (Fructus Crataegi)10 g, Chenxiang(Lignum Aquilariae Resinatum)3 g, Haipiaoxiao (Os Sepiae)10 g , Maozhuacao (Radix Ranunculi Ternati)15 g, Mu xiang (Radix Aucklandiae)10 g, and Gancao(Radix Glycyrrhizae)6 g, 30 doses, administered as a decoction, one dose per day, divided into parts and taken warm.During the second visit after taking the medications, the patient reported that the gastric obstruction and bloating were both alleviated, and the hiccups had resolved.Chenxiang (Lignum Aquilariae Resinatum) was removed from the prescription above,and the patient continued to take the other medicines.Additions and subtractions were made according to the patient’s symptoms.

This patient suffered from liver depression and qi stagnation, liver dysregulation, and the inability to govern dispersion, which affected the spleen and stomach, causing their dysfunction.This resulted in the abnormal ascent of gastric qi, frequent belching,nausea, and gastric discomfort.In this prescription,Dangshen (Radix Codonopsis) and Baizhu (Rhizoma Atractylodis Macrocephalae) served to strengthen the spleen and nourish qi; Shijianchuan (Herba Salviae Chinensis), Banzhilian(Herba Scutellariae Barbatae), Chonglou (Rhizoma Paridis), Baihua Sheshe Cao(Herba Hedyotis Diffusae), Tufuling (Rhizoma Smilacis Glabrae), Yangkaikou (Akebia Puinata), and Shanci gu (Rhizoma Pleionis) served to clear the heat, expel toxins, reduce swelling, and dissipate masses; Wu yao (Radix Linderae), Yujin (Radix Curcumae) and Chenxiang (Lignum Aquilariae Resinatum) served to invigorate qi, relieve pain, warm the middle, and stop the vomiting; Dafupi (Pericarpium Arecae), Chen pi (Pericarpium Citri Reticulatae), Sharen (Fructus Amomi) and Muxiang (Radix Aucklandiae) served to invigorate the stagnation, dispel the swelling, descend qi, and eliminate the bloating; Jineijin (Endothelium Corneum Gigeriae Galli) served to aid digestion,eliminate the bloating, descend qi, and resolve the phlegm; Shanzha(Fructus Crataegi Carbonisatum) served to improve appetite and aid digestion; Hai piaoxiao (Os Sepiae) served to astringe and stop any bleeding, as well as control acid production;Maozhuacao (Radix Ranunculi Ternati) served to resolve the phlegm and dissipate the masses; and Gan cao (Radix Glycyrrhizae) served to relieve spasms and pain, as well as harmonize the other medicinal materials.The combination of medicinal materials in this prescription as a whole accounts for both the origin and superficiality, while also implementing purgation and tonification in equal measure.Therefore, it jointly strengthens the spleen, eliminates dampness, calms the stomach, and suppresses the abnormal ascent of qi, thereby invigorating qi, relieving pain, resolving phlegm, and dispelling stasis, ultimately achieving the function of expelling toxins and eliminating cancer.

Conclusion

In summary, Professor Bai believes that the pathogenesis of gastric cancer is related to the inability of gastric qi to descend, as well as the intermingling of phlegm and stasis.Therefore, the main treatment of excess superficiality for this disease should involve regulating qi, calming the stomach, resolving phlegm,eliminating dampness, invigorating the blood, and dispelling stasis.This disease is located in the stomach and mostly involves the obstruction and stagnation of qi activity in the spleen and stomach, thus impeding function and transformation.Therefore, the treatment for this disease should always focus on protecting the spleen and stomach, preventing damage to healthy qi, and always taking care to safeguard the spleen and gastric qi.This point is especially important in patients with advanced gastric cancer.It is only by supplementing gastric qi and invigorating spleen qi that we can provide qi and blood with sources of production and transformation, and only the regulation of qi activity can support the medicines in eliminating pathogens.In the later stages of this disease, patients may present with syndromes such as gastric heat and damaged Yin, dual qi and blood deficiency, and deficient coldness of the spleen and stomach [6].Therefore, it is necessary to consider both the origin and superficiality, providing both the restoration of normal function and elimination of pathogens.In the treatment of gastric cancer, Professor Bai based the formulation of the prescriptions on the pathogenic mechanisms of qi, phlegm, and stasis, and the prescriptions significantly alleviate clinical symptoms,improve the patient’s quality of life, and prolong survival.