Appreciating a Qing Dynasty Case of Hepatic Ascites Treated by Yu Tinghong

The Qing Dynasty physician Yu Tinghong recorded a case in the "xu-zhang" (vacuity distension) section of his work Yu Tinghong Yi'an (Medical Cases of Yu Tinghong):

The daughter-in-law of Mr. Wei Baoqin, a minor official of Xigong in Changshu, became depressed after losing her husband. Her abdomen was as large as a drum, her waist flattened, her back full, her umbilicus protruding, her limbs emaciated, and when lying down she could not easily turn over. In autumn of the Renwu year I arrived in Qinchuan; the grand secretary Ji Junmei introduced me to the Wei household to examine her. Her facial complexion was greenish and her pulse was string-like and rough.

I said: "String-like belongs to wood being strong; rough indicates qi stagnation; a greenish, dark facial complexion with emaciated limbs and a large abdomen means that wood is overacting on the earth position and the central yang is not moving — hence the abdomen is distended and hard while the limbs are not. This is the syndrome of central vacuity with single abdominal distension. Although all physicians have run out of ideas, the syndrome can still be rescued. Using herbs such as Immature Bitter Orange, Magnolia Bark and Betel Nut to treat a syndrome of strong wood with weak spleen and central vacuity is like punishing the innocent; would it not only ruin things? I fear the righteous qi will not sustain it. We should urgently move qi and soothe the liver, warm the middle and support the earth to restrain wood. Start with Xiangsha Liujun Tang, adding Dried Ginger, Aconitum, Tribulus, Cinnamon Twig, White Peony, Red Date and Sandalwood."

After five or six doses there was no change, but he nonetheless kept this formula as the main basis, modifying it and adding Eucommia, Alpinia Oxyphylla and Citrus Reticulata. After forty or fifty doses the abdominal distension gradually eased and the limb flesh gradually recovered; after more than a hundred doses she was cured. She then took over ten liang of Yu Yuliang Wan and thirty to forty liang of Jinkui Shenqi Wan; the hardness in the abdomen all disappeared, and the illness was resolved.

If we look at the symptoms described in this case, setting aside her mental state, the patient's symptoms — "abdomen as large as a drum, flattened waist, full back, protruding umbilicus, emaciated limbs, unable to turn over when lying down" — closely resemble the hepatic ascites described in modern medicine. Hepatic ascites is mostly caused by severe conditions such as liver cirrhosis and cancer. In the Qing Dynasty when Yu Tinghong lived, there were no sophisticated modern medical instruments to detect the patient's true cause. But he faithfully recorded the patient's clinical symptoms, and today we can make a rough judgment of her condition from those records.

Diseases of this kind were called "gu-zhang" (drum distension) in ancient times, and most physicians would treat them with qi-breaking and accumulation-dispersing herbs such as Immature Bitter Orange, Magnolia Bark and Betel Nut. But Yu Tinghong believed that the patient had "weak spleen and central vacuity," and that treatment should follow the principle: "Seeing liver disease, know that the liver will transmit to the spleen; first solidify the spleen." Hence he chose Xiangsha Liujun Tang (ingredients: Ginseng or Codonopsis, Atractylodes Macrocephalae, Poria, Honey-fried Licorice, Aucklandia, Amomum, Citrus Reticulata, Pinellia, Ginger, Jujube) as the main formula, adding yang-warming Aconitum and Dried Ginger, nutrient-defensive-harmonizing Cinnamon Twig and White Peony, and downward-moving qi and blood-moving Tribulus. The emphasis was on supporting righteous qi and rooting the foundation, with only moderate attack. This treatment approach is relatively safe; it looks slow to take effect, but it is safe.

Only after the patient had taken forty or fifty doses did the abdominal distension gradually lessen, and only after more than a hundred doses did it completely subside. Even after it had completely subsided, Yu Tinghong did not dare let down his guard; he followed up with Yu Yuliang Wan and Jinkui Shenqi Wan — two kinds of pills that supplement with a dispersing component, emphasizing supplementation — and the patient was ultimately fully cured. In this case, the patient's trust in the physician was also key to the eventual success. From Yu Tinghong's records, treatment progressed slowly and the initial herbs had almost no effect; most modern patients would probably not have the patience to continue. But because an acquaintance had made the introduction, this patient trusted Doctor Yu greatly and persisted through forty or fifty doses before her condition eased.

This case is noteworthy in many ways and worth learning from. By the time a disease has progressed to the ascites stage, it is mostly advanced; neither modern nor traditional medicine has many chances of winning against such diseases. At this stage, both physician and patient are prone to impatience for quick results. Especially with today's sophisticated medical instruments, patients easily learn their true condition, feel great psychological pressure, and urgently want to be cured — only to end up with the opposite result.

What we should learn from this case is not only the specific treatment approach, but also this kind of state of mind and bearing when treating disease.