Can’t Urinate, Belly Swollen Like a Drum?

Opening scene: urine won’t come out, and the belly swells like a drum

💬 Note from Doctor Luo: Today’s case is about urinary retention. Difficult urination (urinary discomfort — always feeling there’s urine, passing only a little each time) is very common in Chinese medicine. This patient was more severe — the case is titled “urinary retention”: sometimes he simply could not urinate at all.

The patient was Wang Shanfu, a native of Beijing, whose post was Jingzhao wine official — the official in charge of wine for the capital.

💬 Note from Doctor Luo: Note that job title! A man in charge of wine — he certainly drank. That is the clue to the cause of his illness. Doctor Li always names the patient’s occupation at the start of a case — that is never idle detail.

His symptoms were alarming:

• Urinary retention
• Protruding eyeballs — the eyes bulging outward
• Belly distended like a drum — swollen like a drum; tap it and it goes “thunk” like a watermelon — full of water
• Hard swelling above the knees, the skin about to split — from the knees up the legs were swollen and hard, the skin stretched taut, a fingernail drawn across it looked ready to split open
• Unable to eat or drink — couldn’t get food down, especially didn’t want water

💬 Note from Doctor Luo: This is a breakdown of the body’s water metabolism: the water can’t get out, accumulates inside, and the pressure keeps rising — the eyes pushed out, the belly a drum, the legs swollen until the skin is about to split. Symptoms of all three burners are present: the upper burner (eyes bulging), the middle burner (can’t eat), the lower burner (swollen legs). The damp-water is extraordinarily heavy.

The wrong treatment: warming yang and draining dampness did nothing

Doctors were called, and “liver-kidney dampness-draining herbs all failed” — fu ling (poria), yi ren (coix seed) and other water-draining, dampness-removing herbs were all useless.

💬 Note from Doctor Luo: The usual approach would be: heavy damp-water? Then tonify the spleen and drain dampness — dang shen and bai zhu to tonify the spleen, with fu ling, cang zhu, ze xie, and yi ren to drain the water downward. But here none of it worked — different from the usual case. That’s when Doctor Li was called in.

Doctor Li’s attitude: “this disease is urgent — I must go home and think”

Doctor Li looked at the patient and said: “This illness is very urgent; it cannot be handled here in the capital. I will go home and think about it.” — he needed to think it through carefully before writing a prescription.

💬 Note from Doctor Luo: You see — even a national master cannot treat every disease on the spot. Doctor Li took the patient seriously; he would never say “let’s try this prescription and see.” If he hadn’t figured out the disease, he would never casually prescribe — he always went home and thought it through.

What happened next is even more interesting: in the middle of the night, he suddenly threw on his clothes and rose: “I’ve got it!” — in the middle of the night, he sat bolt upright: “I have it!”

💬 Note from Doctor Luo: This shows Doctor Li hadn’t really been sleeping — lying in bed, his mind kept working on this patient: why was the edema so severe and the urine blocked, when the liver-kidney water-draining herbs had no effect? Suddenly in the middle of the night it clicked, and he explained it to his disciple Luo Tianyi (who was startled half out of his wits).

Pattern analysis: qi transformation — the bladder is a pot, and the fire must be lit underneath

Doctor Li quoted the Neijing:

“The bladder is the officer of the province; fluids are stored therein, and only through qi transformation do they come out.”

💬 Note from Doctor Luo: This deserves a proper explanation of qi transformation (qi hua) and the triple burner — understanding how water moves in the body is the foundation of understanding your own body (we are about 70% water):

• The triple burner is the place where the body’s water moves and transforms (Suwen: “the triple burner is the officer of the drainage ditches; the water passages issue from it”) — it is a fine-grained tissue structure; water moves through it and energy transformation takes place
• The motive force of water metabolism is yuan qi (original qi), and yuan qi is rooted in kidney qi — when kidney qi is sufficient, the lung qi (upper source of water), the spleen qi (middle source), and the bladder/kidney qi (lower source) all function properly
• Qi transformation: under the encouragement of the upright qi (yuan qi, kidney qi), the organs function normally — pushing out the wastes, keeping the nutrients. The ancients compared it to a stove with a fire lit beneath it: with the fire lit, the water on top changes — steam rises, sediment stays behind
• Urination depends on qi transformation — when kidney qi is sufficient and the lower-burner qi is strong, the bladder can be controlled to expel the water

Doctor Li then quoted Wang Bing of the Tang dynasty (styled Qixuanzi, the great editor of the Huangdi Neijing):

“Without yang, yin cannot be born; without yin, yang cannot transform.”

💬 Note from Doctor Luo: This sentence is the key! Yin and yang depend on each other: without yang, yin cannot be born; and without yin, yang cannot transform (yang cannot make the body’s functions perform qi transformation).

Doctor Li’s judgment: the previous doctors had used too many yang herbs (warming yang and draining dampness, fu ling and the like) — supplementing only yang, without attending to yin — “with solitary yang and no yin, how can transformation proceed?” With only yang and no yin, how can qi transformation work normally?

And this Wang Shanfu was a Jingzhao wine official, drinking every day — damp-heat had accumulated in his lower burner. This was heat in the lower burner, a problem of the yin aspect! Using more hot herbs to warm the yang was like pouring oil on the fire — of course it failed.

The prescription: Zi Shen Wan — a formula of all-cooling herbs, cured in one dose

The next day, Doctor Li administered “a formula of the assembled yin” (all cooling herbs) — and it cured him without a second dose! One serving, the water came out, the pressure eased, the symptoms disappeared — well.

That “formula of the assembled yin” was Zi Shen Wan:

How to take: grind into fine powder, boil water and form into pills (the size of a chicken’s head); take about a hundred pills each time, washed down with rolling-boiling hot water, on an empty stomach (don’t let food block the stomach), and afterward stamp the feet twice — to send the medicine downward.

💬 Note from Doctor Luo: The beauty of this formula:

• Zhi mu and huang bai: clear the upper and lower in one sweep — zhi mu clears lung heat (upper burner), huang bai clears lower-burner damp-heat. Doctor Li was especially skilled with these two herbs (the modern Zhibai Dihuang Wan is built on zhi mu and huang bai); when lower-burner damp-heat appears, adding them to a formula cures many diseases, with immediate results.
• A little rou gui: counter-assistance (a formula of entirely cooling herbs would be resisted by the body) plus assisting qi transformation (the fire lit, the water can transform)
• Once the lower-burner damp-heat is cleared and yin-yang is balanced, qi transformation returns to normal and the urine flows

Doctor Li’s principle: this medicine is cold; once the lower-burner damp-heat is cleared, stop — even when the patient begged for more, he wouldn’t give it. This kind of medicine cannot be taken in excess.

Bonus: the same thread of thinking — Professor Zhao Shaoqin treating kidney disease

💬 Note from Doctor Luo: This line of thinking developed into a great deal later. Professor Zhao Shaoqin of Beijing University of Chinese Medicine (my teacher for kidney disease) treated chronic nephritis exactly this way:

The usual approach to kidney-disease edema is to warm yang and drain dampness — but the results are often poor. Professor Zhao held that the kidney channel has damp-heat; the damp-heat binds and causes blood stasis blocking the interior, so the kidneys can’t expel water.

How did he treat it?

• First wind herbs (fang feng, jing jie, bai zhi, du huo) — disperse wind and drain dampness (wind overcomes dampness — this is the Li Dongyuan school’s idea)
• Then cooling and blood-invigorating herbs (huai hua, sheng di yu, dan shen, qian cao to open the collaterals) plus bai mao gen (imperata root) and lu gen (reed rhizome) to clear damp-heat

All cooling herbs — the patient’s urine opens, the water comes out, the edema resolves, the kidneys slowly recover. There were very many such patients.

I once regulated my own elderly mother’s morning leg swelling the same way: elderly leg swelling usually makes you think of warming yang, but my mother’s tongue was red — a yin-deficient constitution. I prescribed shu di huang (prepared rehmannia), sheng di huang (raw rehmannia), sha shen (glehnia), mai dong (ophiopogon) — all yin-nourishing — plus 15 g of raw huang qi and huai shan yao (Chinese yam). The swelling resolved immediately after taking it. My mother even photographed the prescription, saying “this formula works for swelling.”

Treating edema is not only about warming yang — there is also clearing damp-heat, and there is also nourishing yin. Knowing all of these is what makes a complete understanding of Chinese medicine.

Modern takeaway: scalloped tongue edges mean your water metabolism has a problem

💬 Note from Doctor Luo: People with heavy dampness are everywhere today — very thick tongue coating, and scalloped (tooth-marked) edges on the tongue are extremely common. Where do the tooth marks come from? The body’s water can’t get out, so the tongue swells large; pressed against the teeth 24 hours a day, it shows tooth marks the moment you stick it out — this indicates a problem with the body’s water metabolism. Understanding these things lets you protect yourself and your family better.

Case source: Lan Shi Mi Cang (Secrets from the Orchid Chamber) by Doctor Li Dongyuan (compiled by his disciple Luo Tianyi); commentary based on public lectures by Doctor Luo Dalun (PhD in TCM diagnostics, Beijing University of Chinese Medicine).