Appreciating Wang Xiru's Case: Modified Xuefu Zhuyu Decoction for Cirrhotic Ascites

Professor Wang Xiru, former chief physician of internal medicine at the Chongqing Institute of TCM, once treated a patient with cirrhotic ascites. The patient, Gong, was a 53-year-old man whose abdominal distension had progressively enlarged over more than three months; examination confirmed decompensated cirrhotic ascites and he was admitted. After hospital treatment, the distension did not improve, so he was transferred to Professor Wang's hospital for TCM treatment.

On inquiry, Dr. Wang learned that over the previous six months the patient had often felt epigastric and abdominal fullness after meals, somewhat relieved by belching or passing gas; over the most recent three months the symptom had progressively worsened and his abdominal girth had increased daily. Examination found threadlike red veins on the skin of the neck and chest; the abdomen was distended like a drum, hard and globular, with visible abdominal veins. On supination, tapping the anterior abdominal wall produced a drum sound; below the umbilicus on both sides the percussion was dull. When his position was changed, the dullness shifted; jostling the abdomen elicited a fluid thrill, and a hard mass could be felt in the left upper quadrant over the liver. The tongue was dark red with a thin white coating; the pulse was wiry, deep, and rough.

After differentiation, Dr. Wang considered the pattern to be liver-spleen blood stasis, and planned treatment by activating blood and resolving stasis, using modified Xuefu Zhuyu Decoction (Blood-Mansion Stasis-Resolving Decoction). The first prescription was: Bupleurum (chaihu) 10 g; immature bitter orange (zhiqiao) 10 g; red Paeonia (chishao) 15 g; Angelica tail (dangguiwei) 12 g; Chuanxiong 9 g; peach kernel (taoren) 9 g; safflower (honghua) 9 g; Cyathula (chuanniuxi) 12 g; Platycodon (jiegeng) 6 g; Salvia (danshen) 15 g; turtle shell (biejia) 30 g; Motherwort (yimucao) 30 g; and Plantago herb (cheqiancao) 30 g.

After 36 doses of the formula, the abdominal distension gradually subsided. He then continued with Xiangsha Liujun Wan (Aucklandia-Amelia Six-Gentleman Pill) plus some blood-activating, stasis-resolving herbs for more than 40 doses; all symptoms resolved, appetite increased, spirit was good, and weight increased.

According to Professor Wang's own account, in his clinical treatment of cirrhotic ascites, whenever the abdomen was hard and globular, he could basically differentiate it as stasis obstruction (portal hypertension). Such patients not only have difficult urination but also marked qi accumulation; this type of ascites is relatively hard to treat, and should be treated by combining blood activation and stasis resolution, qi regulation and distension reduction, and diuresis and edema reduction.

Dr. Wang's prescription was modified from the Blood-Mansion Stasis-Resolving Decoction of the Qing-dynasty master Wang Qingren (from Wang's Yilin Gaicuo [Correction of Errors in Medical Classics]). Xuefu Zhuyu Decoction (composed of Rehmannia, Chuanxiong, red Paeonia, Angelica, safflower, peach kernel, Achyranthes, Bupleurum, immature bitter orange, Platycodon, and Licorice) is a classic famous formula for activating blood and resolving stasis. It combines the blood-activating Peach-and-Safflower Four-Substance Decoction (Rehmannia, red Paeonia, Chuanxiong, Angelica, peach kernel, safflower) with the Four-Counterflow Powder (Bupleurum, Paeonia, immature bitter orange, Licorice) that regulates qi and reduces distension.

In Dr. Wang's prescription, he removed the greasy, diaphragm-encumbering raw Rehmannia and added blood-activating Salvia and Motherwort, strengthening the blood-moving action; he also added turtle shell, which is specific for cirrhosis, making the treatment more targeted at cirrhosis. Motherwort and Plantago herb are both diuretic, edema-reducing herbs, and both were used at relatively high doses.

In treating this patient, Dr. Wang did not simply treat ascites with diuretics; rather, targeting the specific cause, he treated both root and manifestation with great precision. Had this patient used only diuretic formulas such as Wuling San, the result would not have been so good.

In my humble opinion, if Professor Wang Xiru's case is combined with Professor Qian Ying's experience (of Beijing Traditional Chinese Medicine Hospital) in treating cirrhotic ascites—adding Aucklandia (muxiang) 10 g and Magnolia bark (houpo) 10 g to Professor Wang's formula—the effect might be even better.