Appreciation of Three Cases: Li Shimao Treating Ascites due to Cirrhosis

Professor Li Shimao (deceased) was a professor and doctoral supervisor at Hebei University of Chinese Medicine. With more than 50 years in medicine, he was rich in both teaching and clinical experience. Case records of some of the cirrhosis-with-ascites patients he treated are included in Xiangru Yiji (Collected Medical Writings of Mutual Affection), coauthored by Professor Li Shimao and his wife, Professor Tian Shuxiao. From these cases we can see the distinctive features of Professor Li Shimao's treatment of ascites due to cirrhosis. This article excerpts three of his cases and offers commentary, so as to learn from his experience.

Case 1: Patient Xu with ascites due to cirrhosis complicated by pleural effusion

Xu, a 35-year-old male, was a truck driver. He had a 12-year history of hepatitis, which worsened at the end of 1976. He had frequent fever around 38 C, recurrent epistaxis, nausea, poor appetite, abdominal distention, right upper-quadrant pain, jaundice of skin and sclera, multiple spider angiomas on the chest and neck, positive ascites, liver enlarged 1.5 cm below the costal margin, spleen enlarged 2 cm and of medium consistency with tenderness, and pitting edema of the lower limbs. Western medicine diagnosed ascites due to cirrhosis with abnormal liver function.

After half a year of integrated Chinese-Western treatment, his condition steadily worsened. The ascites increased progressively; abdominal girth reached 110 cm, the diaphragm was level with the 7th thoracic vertebra, and the scrotum was enlarged to the size of an infant's head. Excessive abdominal pressure produced an inguinal hernia. Daily urine output was only about 200 ml, and he was bedridden, unable to turn over.

At the visit his complexion was dark and dull, skin and eyes were jaundiced, he had nausea and vomiting, the skin was scaly and dry (chicken-skin), he felt restless feverish without sweating, was thirsty and favored cold drinks (especially at night), the abdomen was distended like a drum with a protruding umbilicus, the tongue was deep red with little coating, and the pulse was wiry and rapid. Professor Li differentiated the pattern as blood stasis with phlegm obstruction and planned treatment by activating blood and softening hardness.

The first-visit prescription: Taoren (peach kernel) 9 g, Honghua (safflower) 9 g, Wulingzhi (trogopterus dung) 15 g, Chishao (red peony) 9 g, Danshen (Salvia) 15 g, Mudanpi (Moutan bark) 12 g, Qinghao (sweet wormwood) 12 g, Yujin (Curcuma) 6 g, Shengdihuang (raw Rehmannia) 12 g, Yinchaihu (Stellaria root) 6 g, Shengmuli (oyster shell) 30 g, Haizao (Sargassum) 15 g, Xuanshen (Scrophularia) 12 g.

After 23 doses, abdominal girth gradually decreased to 84 cm and 24-hour urine output rose to 1800 ml. He then switched to the method of nourishing yin, boosting qi, and softening hardness until mid-October, when the ascites resolved. But suddenly a large pleural effusion appeared, so he switched to draining the lung and resolving stasis; by November 14 the pleural effusion had also completely resolved. In January 1978 the jaundice faded, subjective symptoms disappeared completely, and repeated liver-function tests were normal. He was discharged on March 12 of that year, after which he took blood-activating, hardness-softening pills for consolidation. Follow-up for 2 years showed no recurrence.

Case 2: Patient Yan with ascites due to cirrhosis complicated by pleural effusion

Yan, a 56-year-old housewife, had suffered from ascites due to cirrhosis for over 5 months without improvement after Western treatment. A TCM consultation was requested on October 14, 1976. At the consultation, the patient had a large abdomen but thin limbs, a fine rapid pulse, and a glossy deep-red tongue with no coating. Previous doctors had used diuresis, spleen-fortifying, blood-activating, and water-expelling methods, all without effect. Considering that the glossy, deep-red, coatingless tongue (a mirror tongue) indicated yin deficiency, Professor Li planned treatment by nourishing yin and resolving stasis.

The first-visit prescription: Shengdihuang (raw Rehmannia) 30 g, Xuanshen (Scrophularia) 15 g, Mudanpi (Moutan bark) 10 g, Shanzhuyu (cornus fruit) 15 g, Chishao (red peony) 12 g, Baishao (white peony) 12 g, Shengmuli (oyster shell) 30 g, Zhibiejia (prepared turtle plastron) 30 g, Zhimu (Anemarrhena) 6 g, Sheng Guiban (turtle shell) 30 g.

After 3 doses urine output began to increase; after a further month the ascites completely resolved, and Jisheng Shenqi Pill was given for consolidation.

Case 3: Patient Liu with ascites due to cirrhosis and exuberant toxin-heat

Liu, a 52-year-old female, had suffered from cirrhosis for 7 years. Her abdominal wall veins were engorged, looking like crawling earthworms; she had recurrent epistaxis and gingival bleeding and had had three major hematemeses. She felt restless and hot, ate little, and was emaciated. The pulse was wiry, rapid, large, and forceful; the tongue was red with little coating. Master Li differentiated this as exuberant toxin-heat forcing blood to move recklessly, and planned treatment by modifying Qingwen Baidu Drink.

The first-visit prescription: Shuiniujiao (buffalo horn) 30 g (decocted first), Lingyangjiao (antelope horn) 3 g (decocted first), Zhibiejia (prepared turtle plastron) 30 g (decocted first), Shengmuli (oyster shell) 30 g (decocted first), Daqingye (Isatis leaf) 10 g, Shengshigao (gypsum) 30 g, Mudanpi (Moutan bark) 12 g, Zhimu (Anemarrhena) 6 g, Chishao (red peony) 12 g, Lianqiao (forsythia) 15 g, Luhui (aloe) 10 g, Jiaozhizi (fried cape jasmine) 10 g, Longdancao (gentian) 6 g, Shengdihuang (raw Rehmannia) 15 g, Zhuye (lophatherum) 6 g, Xuanshen (Scrophularia) 15 g, Huanglian (Coptis) 10 g, Sheng Gancao (raw licorice) 6 g.

After 36 doses with modifications, epistaxis and gingival bleeding ceased, the fever resolved, and the pulse became moderate. He then switched to consolidating by activating blood, softening hardness, nourishing yin, and emolliating the liver.

The second-visit prescription: Zhibiejia (prepared turtle plastron) 30 g (decocted first), Sheng Guiban (turtle shell) 30 g (decocted first), Shengmuli (oyster shell) 30 g (decocted first), Mudanpi (Moutan bark) 10 g, Ezhu (curcuma) 10 g, Shengdihuang (raw Rehmannia) 15 g, Jianghuang (turmeric) 10 g, Baishao (white peony) 15 g, Haizao (Sargassum) 12 g, Xiakucao (prunella spike) 12 g, Chishao (red peony) 12 g, Dilong (earthworm) 10 g, Sanleng (burreed) 10 g, Shuizhi (leech) 5 g.

Thereafter, with modifications of the above, treatment continued for 9 months in all; the patient's symptoms resolved, the engorged abdominal-wall veins disappeared, and she recovered her health.

These three cases are, in Western medicine, the same disease: ascites due to cirrhosis. These patients had previously seen both Western and Chinese doctors. The earlier TCM treatments were ineffective, because most TCM doctors treating ascites still like to "treat water when they see water," using Wuling Powder, Zhuling Decoction, Weiling Decoction, and the like, with poor results.

Such refractory liver-ascites patients, unresponsive to prolonged treatment, basically have intractable ascites. They have already used many Western diuretics; adding TCM diuretics will not produce much effect. Hence, treating such patients calls for another approach. The three cases Professor Li treated all had typical TCM patterns.

The first case had scaly, dry skin—a typical sign of blood stasis. In the Han dynasty, Zhang Zhongjing treated patients with scaly dry skin with such formulas as Dahuang Zhechong Pill, Xiayu (Blood-Dispelling) Decoction, and Biejiajian Pill, emphasizing activating blood and resolving stasis while downplaying spleen-fortifying and diuresis. Professor Li treated with modifications of Taohong Siwu Decoction, exactly matching Zhang Zhongjing's approach, and therefore his formula was effective.

The second patient's tongue was already glossy, deep red, and coatingless; continuing diuresis would not only fail but also risk "yin desertion." So Professor Li treated with modifications of Zengye Decoction, adding Shanzhuyu, Guiban, and Zhimu to clear heat and increase the force of nourishing yin. Zengye Decoction (composed of Xuanshen, Maidong, and Dihuang) is a classic formula for nourishing yin and generating fluids; basing the formula on it fully exploited the advantage of TCM pattern differentiation.

The third patient had not only yin deficiency but also fever. To treat her, one should wait until the fever subsides and yin recovers before activating blood and softening hardness. Master Li first used Qingwen Baidu Powder to clear heat and detoxify and resolve the exterior pattern, then used blood-activating and stasis-resolving methods to break hardness and disperse nodules. It took nearly a year before the patient recovered, which was no easy feat.

From these cases it can be seen that for complicated liver ascites, TCM has no fixed formula; the physician must master superb pattern-differentiation skills and have deep research into TCM diagnostics, formula studies, and materia medica in order to achieve results. If such a patient does not meet an excellent physician, most will simply die untreated. That Master Li was able to rescue them is truly "rescuing the dying and healing the wounded."