A Case Commentary: Professor Lu Fang Treating Cirrhotic Ascites

Professor Lu Fang was a TCM professor at Heilongjiang University of Chinese Medicine. He formerly served as director of Harbin Municipal Hospital of Traditional Chinese Medicine and as deputy director of the Heilongjiang Provincial Administration of Traditional Chinese Medicine. He was a national mentor of renowned veteran TCM experts, a nationally recognized TCM master, and enjoyed the State Council special government allowance. Professor Lu came from a TCM family; he graduated from Heilongjiang College of Traditional Chinese Medicine in 1961 and, on account of his outstanding scholarship and conduct, remained at the college to teach. He authored monographs including Lu Fang's Clinical Thinking.

Professor Lu excelled in treating various difficult and complicated diseases as well as major illnesses. On November 15, 1990, he saw a 36-year-old male patient with cirrhosis, surnamed Zhang. At the time of consultation, Zhang presented with a distended, swollen abdomen due to hepatic ascites, a mass under the left rib, thirst, and limited mobility. The patient had a history of more than 20 years of hepatitis B and had previously been diagnosed at other hospitals with cirrhosis, hepatosplenomegaly, and hepatic ascites. He appeared chronically ill, with a purplish-dark tongue, white greasy coating, and a fine, wiry, rapid pulse; abdominal wall veins were dilated, the abdomen was frog-shaped, and shifting dullness was positive.

Professor Lu's pattern differentiation was accumulation of heat-toxin with blood stasis in the liver and spleen, so he treated the patient with his self-designed Sheban Decoction. The initial prescription was: Banzhilian (Scutellariae Barbatae Herba) 50 g, Baihuasheshecao (Hedyotidis Diffusae Herba) 50 g, Zhi Biejia (processed Amydae Carapax) 15 g, Danshen (Salviae Miltiorrhizae Radix) 50 g, Cheqianzi (Plantaginis Semen) 50 g (packeted separately), Fuling (Poria) 50 g, Baizhu (Atractylodis Macrocephalae Rhizoma) 15 g. Seven doses, decocted in water, one dose daily.

After taking seven doses, the patient returned reporting no discomfort and increased urine output. Following the ancient maxim that "if a formula is effective, do not change it," Professor Lu instructed him to continue the same formula for another seven doses. After these further seven doses, the abdomen felt markedly lighter and urine output increased. The tongue remained dark with a thin white coating; the abdomen was soft and ascites had decreased. He then added Zhe Beimu (Fritillariae Thunbergii Bulbus) 15 g, Xiakucao (Prunellae Spica) 15 g, and Danggui (Angelicae Sinensis Radix) 15 g to clear heat and cool the blood, activate blood and soften hard masses; seven doses, decocted in water.

After another seven doses, follow-up B-ultrasound showed that ascites had disappeared and the spleen had shrunk, though cirrhosis had not yet resolved. The tongue was dark with a thin white coating and the pulse was wiry. Professor Lu reasoned that since ascites had already resolved, strong diuretics should no longer be used; he stopped the previous formula and switched to the method of supplementing qi, activating blood, and softening hard masses.

The prescription was: Huangqi (Astragali Radix) 50 g, Chishao (Paeoniae Rubra Radix) 50 g, Danshen (Salviae Miltiorrhizae Radix) 50 g, Zhi Biejia (processed Amydae Carapax) 15 g, Wangbuliuxing (Vaccariae Semen) 25 g, Zelan (Lycopi Herba) 50 g. Seven doses, decocted in water.

After a further seven doses, repeat B-ultrasound showed that the liver and spleen had returned to normal. He was then told to continue the final formula for another seven doses as consolidation.

The cirrhosis in this patient had gradually evolved from chronic hepatitis. Cirrhosis is a serious disease; left unchecked, this patient might have progressed to liver cancer, which would have been far more difficult to treat. Professor Lu's prescriptions were distinctive: he used few herbs, but at very large doses. Banzhilian, Baihuasheshecao, Danshen, Cheqianzi, Fuling, Chishao, Huangqi and others were each used at the equivalent of about 50 g (one liang), exceeding the conventional dosage, yet they took effect rapidly. As the patient's symptoms eased after taking the medicine, he quickly developed confidence in Professor Lu's approach. This is crucial in treating major illness: rapid results build firm trust between doctor and patient, making subsequent treatment proceed smoothly.

TCM has long held that "heavy doses resolve stubborn chronic disease," yet deciding when to use heavy doses and when to use light ones is difficult. If a formula is inappropriate, overdosing not only fails to treat the disease but may cause severe side effects. Using heavy doses therefore requires a physician of deep grounding, with accurate pattern differentiation before daring to do so.

At the first visit, the patient had severe ascites, so promoting urination had to be the priority; diuretics such as Cheqianzi and Fuling were therefore used in large doses. But this was only treating the branch. The disease arose from hepatitis B, so heavy doses were also needed to combat the virus; hence heat-clearing, toxin-resolving herbs such as Banzhilian and Baihuasheshecao were also used at 50 g. The patient already showed blood stasis, so Danshen, which activates blood and resolves stasis, was likewise used at a heavy 50 g. Given such large individual doses, the formula itself could not be large; a large formula with large doses would be more than the patient's body could bear. Professor Lu's formulas therefore contained only a few herbs, kept very concise.

From this approach one can discern the legacy of Zhang Zhongjing. Zhang Zhongjing used herbs with great precision; his formulas were mostly small, but the dosages were large, often several liang (one Han liang equals about 15 g today). Such dosing yields strong, focused effect and often produces immediate results.

Learning TCM should not rigidly follow a single line of thinking. We should draw from many sources and study several prescribing approaches so that our therapeutic thinking never runs dry.