Muli Zexie San for Pleural and Ascitic Fluid

Muli Zexie San is from Shanghan Lun. It consists of equal parts Muli (Ostreae Concha, calcined), Zexie (Alismatis Rhizoma), Shuqi (Dichroae Folium, washed in warm water to remove fishy odor), Tinglizi (Descurainiae/Lepidii Semen, calcined), Shanglugen (Phytolaccae Radix, calcined), Haizao (Sargassum, washed to remove salt) and Gualougen (Trichosanthis Radix, i.e. Tianhuafen). Grind the seven herbs together into a fine powder. Take an appropriate amount (1-3 g) each time with plain water, three times daily. Muli Zexie San is a diuretic; stop when urination becomes free.

This formula promotes urination and defecation. Muli, Zexie, Tinglizi, Shanglugen and Haizao all promote diuresis; Shuqi, Gualougen and Shanglugen also induce purgation. Gualougen, Shanglugen, Muli and Haizao all reduce swelling and soften hardness. Used together, they treat ascites (or pleural effusion) with obstructed urination and defecation, and also have some anti-tumor action.

Shanghan Lun uses Muli Zexie San for 'after a major illness resolves, when there is water qi below the waist.' According to Shanghan Lun's indications, the pattern is edema below the waist, but with intact upright qi, good strength, difficult urination and defecation, and a deep, forceful pulse. Modern use includes pleuritic effusion, cirrhotic ascites and cancerous ascites, with some effect; clearly its indications are not limited to edema below the waist--'suspended rheum' above the waist also responds.

However, Shanglu (Phytolacca) in this formula is toxic and many pharmacies do not sell it. Shuqi is the stem of Changshan (Dichroa febrifuga), also toxic, and most pharmacies do not stock it either. So this formula is hard to assemble at an ordinary pharmacy; patients who want it must find the herbs themselves.

Linzheng Zhinan Yi'an records a case by Ye Tiansu using this formula for edema: 'A man, choppy pulse, leakage whenever yang qi moves, gurgling in the right hypochondrium with water dropping into the lower abdomen; hence the swelling is not due to obstruction of the yang tract but to excess in the yin tract, the damp-heat of food and water not being transformed. Consider Muli Zexie San: left Muli, Zexie, Tianhuafen (i.e. Gualougen, also called Tianhuafen), Chuan Guizhi wood, Fuling, purple Houpo; taken at noon and cured.' The 'yang tract' and 'yin tract' Ye Tiansu mentions are specialized TCM terms, not the anatomical vagina of modern medicine. Here 'yang' roughly corresponds to the six fu organs, and 'yin' to the five zang organs.

Li Haipeng left another case. An elderly woman had had pulmonary tuberculosis for over ten years, recurrent, now and then milder or worse, with pain in the chest and hypochondrium as if separated, and alternating chills and fever. Western antituberculous drugs relieved the symptoms somewhat, but cough, wheezing and pain continued. X-ray showed right exudative pleurisy. Li Haipeng therefore used Muli Zexie San as the main formula, supported by root-fortifying herbs: Duan Muli (calcined oyster shell) 30 g, Zexie 15 g, Tinglizi 15 g, Shanglugen 6 g, Gualougen 30 g, Haizao 15 g, Hongshen (red ginseng) 10 g, Danggui (Angelica) 10 g, Huangqi (Astragalus) 15 g. Five doses, one daily, morning and evening.

After taking it, the patient first felt heat, stuffiness and nausea; on the second dose, bowel sounds, followed by diarrhea of thin sputum-like fecal water, after which the chest immediately felt open and the breath easy. She then took more than 20 more doses; a repeat X-ray showed the pleural effusion had completely gone. The Shanglugen, Shuqi and Tianhuafen in this formula all cause purgation, so patients may develop bowel sounds, abdominal pain and diarrhea as side effects. Li Haipeng's case records the patient's reactions in detail. Although these side effects appeared, the same herbs treated the disease--this is what Chinese medicine means by 'if the medicine does not produce a blinding reaction, the stubborn disease will not be cured.'

Muli Zexie San's treatment logic is instructive: diuresis and purgation can indeed relieve edema. But in modern practice, patient safety must come first; we need not necessarily use such highly toxic herbs as Shuqi and Shanglu. As early as the Qing dynasty, Ye Tiansu replaced Shanglu and Shuqi with milder Guizhi, Fuling and Houpo. This safer approach is worth emulating.