Appreciating Professor Zhang Zesheng's Case of Severe Liver Abscess
Professor Zhang Zesheng (1895–1985) was a great physician trained through the TCM apprenticeship lineage. Beginning at age 16, he studied for six years under He Jiheng, a top disciple of Fei Boxiong of the Menghe current, and fully received his transmission. In 1919 he began to practice medicine and soon became a famous physician in his hometown of Danyang, Jiangsu. After the founding of New China, he answered the national call and went to work at the Jiangsu Provincial Hospital of TCM, also serving as a professor at Nanjing University of Chinese Medicine. Professor Zhang was skilled in TCM internal medicine, excelling at spleen-stomach disorders and difficult, complicated cases. Below is a selected case of his treating a severe liver abscess, so that we may learn his therapeutic thinking.
The patient, a 30-year-old woman surnamed Wang, first consulted Professor Zhang on April 27, 1974. At the visit she had a high fever above 40°C, limb pain, and severe pain under the right rib-side. Her tongue was red with a yellow, greasy coating, and her pulse was deep and rapid. Western medicine diagnosed a bacterial liver abscess; pus had already been aspirated twice and antibiotics used, with poor effect and progression of the disease. Professor Zhang differentiated the pattern as liver depression and qi stagnation with stasis-heat obstructing the interior, and planned treatment by clearing heat, resolving toxins, supporting the interior, and expelling pus.
Initial prescription: honeysuckle flower (jinyinhua) 15g, forsythia fruit (lianqiao) 9g, whole Chinese angelica (danggui) 9g, bupleurum root (chaihu) 5g, scutellaria root (huangqin) 9g, Chinese honeylocust spine (zaojiaoci) 9g, raw astragalus root (sheng huangqi) 15g, dandelion herb (pugongying) 30g, raw licorice (shenggancao) 3g.
By May 7 the patient returned for a second visit. After taking 5 doses of the initial formula, her fever had gradually decreased and bowel and bladder movements were normal; she still felt pain under the rib-side on deep inspiration. Repeat ultrasound showed the liver abscess lesion had not yet fully resolved. The tongue coating was thin and yellow, and the pulse was fine and wiry. Since the initial prescription had worked, the overall therapeutic principle should not change; Professor Zhang decided to continue along the initial line with slight adjustments.
Second-visit prescription: whole Chinese angelica (danggui) 9g, white peony root (baishao) 9g, safflower (honghua) 9g, Chinese honeylocust spine (zaojiaoci) 9g, bupleurum root (chaihu) 5g, raw astragalus root (sheng huangqi) 15g, dandelion herb (pugongying) 15g, honeysuckle stem (rendongteng) 15g, raw licorice (shenggancao) 3g.
At the third visit on May 21, 1974, the fever had resolved and right rib-side pain had lessened. Repeat ultrasound showed no fluid level. The tongue coating was yellow and greasy, and the pulse was fine and wiry. Treatment continued by clearing the liver and harmonizing the collaterals; on the basis of the second prescription, 12g of whole trichosanthes fruit (gualou) was added. After several more days of modulation the patient fully recovered.
Liver abscess is a critical, severe condition: a pyogenic lesion forming inside the liver due to infection by bacteria, amoebae, or other pathogens. Typical symptoms include fever, right upper abdominal pain, and tenderness over the liver region. Western treatment relies mainly on antibiotics, drainage, or surgery. This patient had already received a standardized Western regimen before seeing Professor Zhang, without effect. Her condition progressed rapidly, with a high fever reaching 40°C; if treatment had not quickly shown effect, her situation would have been very dangerous.
The initial prescription can be read as a half-and-half combination of Wuwei Xiaodu Yin (Five-Ingredient Decoction to Resolve Toxins) and Xiao Chaihu Tang (Minor Bupleurum Decoction), with modifications. Wuwei Xiaodu Yin consists of five herbs—honeysuckle, dandelion, viola herb, wild chrysanthemum, and crowfoot root—and mainly clears heat and resolves toxins. Xiao Chaihu Tang consists of bupleurum, scutellaria, pinellia, ginseng, and licorice; it has a good fever-relieving effect and is the representative formula for Shaoyang disease.
The disease was in the liver, exactly where the Shaoyang channel resides, and the abscess meant the liver already had inflammation and pus. Thus Xiao Chaihu Tang treated the fever, Wuwei Xiaodu Yin cleared the heat-toxin, Chinese angelica invigorated blood, and honeylocust spine expelled pus. Forsythia both helped Wuwei Xiaodu Yin clear heat and helped Xiao Chaihu Tang reduce fever, and also assisted honeylocust spine in expelling pus; raw astragalus boosted qi and supported the righteous. Such a combination was precisely on target.
After the patient improved, Professor Zhang added safflower to invigorate blood and stop pain, and white peony to soften the liver, nourish blood, and stop pain, addressing her rib-side pain. At the third visit, whole trichosanthes was further added to expel pus and dissipate nodules and consolidate the effect. This prescribing follows Zhang Zhongjing's principle of "when the pattern is present, use the corresponding herb"; the method is rigorous, and every addition or subtraction aims at a specific target—truly the bearing of a great master.