Diarrhea at Night, Ice-Cold Hands and Feet, Blue Lips? Doctor Luo Tianyi’s Spleen-Stomach Deficiency Cold Case (Huangqi Jianzhong Tang / Astragalus Middle-Fortifying Decoction)

Patient search words: diarrhea at midnight / cold hands and feet / cold palms / slight stomach ache / no appetite / blue lips ｜ Medical terms: pi wei xu han (spleen-stomach deficiency cold) · gan qi heng ni ke pi tu (liver qi running sideways and overwhelming the spleen) · xu lao li ji (fatigue with acute interior tension) · shui xie mu shi (water pathogen exuberant, wood replete)

The opening scene: diarrhea in the middle of the night, and the imperial physician summoned by dawn

The Yuan dynasty. Zhending Circuit. In the middle of the night, a high official suddenly came down with diarrhea — twice before morning. The moment the sky began to lighten, without a second thought, he sent someone to fetch Doctor Luo Tianyi to his home: Something is definitely wrong with my body — please, come and have a look!

The official was Liu Zhongmei (刘仲美), the zongguan (chief administrator) of Zhending Circuit.

💬 Note from Doctor Luo: A “lu” (circuit) was an administrative unit in the Yuan dynasty, and the “zongguan” was the leader of that circuit — roughly what we would call the mayor of a city today. Zhending is today’s Zhengding in Hebei Province — both Doctor Li Dongyuan and Doctor Luo Tianyi, master and student, lived in this area, which is why so many famous physicians’ case records survive from here.

Who was the patient? A leader past sixty, with a long history of spleen-stomach deficiency cold

The very first line of the case record gives his age: Liu Zhongmei was past sixty (nian yu liu xun) — in his sixties.

💬 Note from Doctor Luo: Notice this: when the ancients treated a patient, the first thing they did was look at age and life circumstances — this information is critical. In those days, being past sixty was already a very great age, and the body behaved completely differently from a young person’s.

And he had long suffered from spleen-stomach deficiency cold (su you pi wei xu han) — for years his spleen and stomach had been cold and weak, giving him all sorts of trouble. This was his old medical history.

Where did the illness come from? An overcast intercalary eighth month + official toil + one glass of cold water

Doctor Luo Tianyi liked to tease apart the causes of an illness one by one:

First, the weather. That year had an intercalary eighth month (run ba yue). The weather in an intercalary eighth month is not normal — in an ordinary year the eighth month should still be warm, but that year, at the start of the eighth month, the weather turned yin and cold (yin han), with a chill in the air.

Second, official duties. Liu Zhongmei “suffered from the toil of official business (yin guan shi lao yi)” — as an official, he was extremely busy.

💬 Note from Doctor Luo: “Official toil” must be unpacked in two layers. One layer is consumption — his work was frantic, draining his physical strength and energy. The other layer is emotional pressure — when orders come down from above, they must be carried out, and the pressure is enormous. One is consumption, the other is stress, and both damage the body.

Third, the last straw: thirst, and drinking cold. He was thirsty, so he drank a few mouthfuls of cold water (yin leng).

Already old, already spleen-stomach deficient and cold, hit by overcast weather, worn out and stressed by work — and then a glass of cold water went down. That did it: ye ban zi li — diarrhea began in the middle of the night, and he went twice.

How bad was it? Ice-cold limbs, and lips and tongue tinged with blue

At dawn he called in Doctor Luo Tianyi, who took his pulse: mai xuan xi er wei — wiry, thin, and faint.

Then he looked at the man: his four limbs were cold, and his palms too; fu zhong wei tong — slight pain in the abdomen; qi duan — shortness of breath, breathing was labored; bu shi yin shi — his appetite was terrible, he wanted nothing to eat.

And the most important sign: his lips and tongue both had a brownish (se) tinge — the color of his lips and tongue was off.

💬 Note from Doctor Luo: Here is a small detail: in this case Doctor Luo Tianyi writes “brown (se),” yet later in the text he always calls it “blue (qing).” This may be a slip of the brush, or in those days “brown” may have carried the sense of blue — in any case the color was abnormal, and Doctor Luo Tianyi analyzed it as “blue.”

The diagnostic highlight: Doctor Luo Tianyi thought one layer deeper — this illness had to do with the liver

How would an ordinary doctor think? The weather is cold, the patient has long been spleen-stomach deficient and cold, and he drank cold water and got diarrhea — so, warm the yang (wen yang)!

Doctor Luo Tianyi was not so simple. He stared at the patient’s lips and tongue and thought much deeper.

The Neijing says: “Se qing zhe gan ye” — the color blue belongs to the liver. Blue corresponds to the liver — the liver belongs to wood; and the lips correspond to the spleen — the spleen belongs to earth. The lips showing a blue tint — what does that mean? Wood comes to overpower earth (mu lai ke tu) — constrained liver qi and emotional disturbance had stirred up trouble in the spleen and stomach!

💬 Note from Doctor Luo: Let me share a diagnostic experience: people with constrained liver qi and bad moods often show a faint, hidden blue tint in the ring around the lips; some also show it around the nose; in severe cases, the whole ring from the nose to the lips is faintly blue. So “wood overpowers earth” is not empty talk — you can see it on the face. Of course, blue lips are also common in cold patterns and in congealed qi and blood — but liver qi running sideways and overwhelming the spleen most often shows up precisely in the ring around the lips.

Then the tongue. The tongue is the sprout of the heart (she wei xin zhi miao) — the tongue corresponds to the heart. What does a tongue with a bluish tint mean? Doctor Luo Tianyi’s explanation: shui xie mu shi, zhi huo ling pi — the water pathogen is exuberant and the wood is replete, suppressing the fire and bullying the spleen. Dampness (water) was too heavy, pressing down the heart fire; and why did the water run rampant? Because liver qi was stagnant (gan qi yu zhi) — it abetted the flood and crushed the heart fire.

💬 Note from Doctor Luo: From modern experience, a bluish tongue usually has to do with three things: first, blood stasis — stasis often gives the tongue a blue-purple cast; second, cold — when the body is chilled the tongue can turn blue; third, liver disease — for example, some people with liver cancer develop a “liver crease line (gan ying xian)” on both sides of the tongue body, a deep-blue line; people with this tongue sign who go for a check-up often turn out to have serious liver disease. So a blue tinge on the tongue really is connected to the liver.

So Doctor Luo Tianyi judged: for Administrator Liu’s illness, one must not think only of cold exposure — one must also think of constrained liver qi and emotional problems. He looked one layer deeper than other doctors.

The theoretical foundation: one line from the Nanjing + one rule from Zhang Yuansu + one system from Qian Yi

Where did Doctor Luo Tianyi’s confidence come from?

First, the Nanjing (Classic of Difficulties): “Seeing the liver is diseased, one knows the liver will transmit to the spleen, therefore first fortify the spleen qi (jian gan zhi bing, ze zhi gan dang chuan zhi yu pi, gu xian shi qi pi qi).” Zhang Zhongjing had said the same thing — since the spleen has already been “bullied” by the liver, the urgent task is first to fortify the spleen qi.

Second, Zhang Yuansu (the old man of Jiegu, 张元素 洁古老人): he said “suppose one of the five viscera is hyperactive and running out of control; tonify the one that cannot win, and drain the one that is winning (bu bu sheng er xie qi sheng).”

💬 Note from Doctor Luo: What does this mean? When one of the five viscera becomes hyperactive and starts behaving abnormally, it bullies the viscus it normally controls — liver wood bullies spleen earth. What to do? Tonify the one that cannot win, drain the one that is winning: generously, heavily nourish the bullied one (the spleen-earth) so it grows strong and keeps functioning normally; at the same time mildly “drain” the bully (the liver-wood), soothing it and keeping it from running amok. This rule — “heavily tonify the defeated, gently drain the victorious” — is the general principle for treating this class of illness.

Third, Qian Yi (钱乙). The system of five-viscera pattern differentiation was developed and perfected by Qian Yi of the Song dynasty — the founding father of Chinese pediatric medicine.

💡 Note from Doctor Luo: The five viscera have both restraining and generative relationships — one side engenders, the other restrains, and the body lives in a stable equilibrium. Once that equilibrium is broken, a person falls ill. Chinese medicine treats illness by helping you restore that balance. This system of five-viscera pattern differentiation is still in use today.

A modern confirmation: more than half of stomach ulcer patients carry heavy emotional stress

Doctor Luo Dalun adds a special point: this “treat liver and spleen together” approach works just as well today.

💬 Note from Doctor Luo: Of the stomach ulcer patients I have seen, besides irregular eating, the more common cause is heavy emotional stress — this is a conclusion we reached through a great deal of research and many trials. If you look only at the stomach itself — studying how to suppress gastric acid, how to repair the ulcer surface — you are really only treating the branch (zhi biao). The true root treatment (zhi ben) is reducing your stress so you stop being anxious. How did the ancients describe this? “Liver qi runs sideways; wood comes to overpower earth” — emotional disturbance causes spleen-stomach problems. With the generation and restraint of the five phases, the ancients described this complex relationship with perfect clarity — the model is very well built. Today’s case is a typical example of flexibly applying the generation-restraint relationships of the five viscera to treat illness.

The prescription: Huangqi Jianzhong Tang with added shaoyao and fuzi — Zhang Zhongjing’s formula doing two jobs at once

For Liu Zhongmei’s illness, Doctor Luo Tianyi prescribed Huangqi Jianzhong Tang (Astragalus Middle-Fortifying Decoction, 黄芪建中汤), with shaoyao (white peony) and fuzi (prepared aconite) added.

💬 Note from Doctor Luo: This formula is a classic — it is the formula I most often recommend for stomach ulcer patients.

Where does it come from? The very first formula in Zhang Zhongjing’s Shanghan Lun (Treatise on Cold Damage) is Guizhi Tang (Cinnamon Twig Decoction, 桂枝汤): guizhi (cinnamon twig), baishao (white peony), zhi gancao (honey-fried licorice), shengjiang (fresh ginger) and dazao (red dates) — harmonizing the nutritive and defensive qi (ying wei). When the nutritive and defensive qi are in harmony, a person with weak constitution can recover from a common cold on their own.

💬 Note from Doctor Luo: There is a secret here. Why did Zhang Zhongjing put Guizhi Tang first in the whole book? Because he valued fortifying the upright qi. What is the core of Guizhi Tang? — tonifying the middle, regulating the spleen and stomach! You can see it from how the formula transforms: double the amount of shaoyao in Guizhi Tang and add yitang (maltose), and it becomes Xiao Jianzhong Tang (Minor Middle-Fortifying Decoction, 小建中汤) — for fatigue with acute interior tension (xu lao li ji); add huangqi (astragalus) and it becomes Huangqi Jianzhong Tang — for spleen-stomach weakness, a very depleted body, and cold-abdominal-pain “fatigue” patterns. So Guizhi Tang in the blink of an eye becomes a middle-fortifying formula — that is its true nature.

Now look at how Doctor Luo Tianyi modified it:

• Shaoyao (white peony) — sour in flavor; softens the liver and restrains the liver (rou gan, lian gan). The formula is for tonifying the spleen and stomach — why deliberately add one herb to soothe the liver-wood? Because Zhang Zhongjing long ago knew “seeing the liver diseased, know the liver transmits to the spleen, and first fortify the spleen” — but merely tonifying the spleen is not enough; the liver must also be soothed — that is “drain the one that is winning”: stop bullying the spleen, settle down, and do what you are supposed to do. Shaoyao is crucial here.
• Huangqi and gancao — sweet and warm; tonify the spleen-earth. This is “heavily tonify the one that cannot win”: generously aid the bullied spleen.
• Guizhi and fuzi — pungent and hot; discharge the cold-water pathogen, assist the yang and repel the yin (xie qi han shui, zhu yang tui yin). When yin qi is excessive and yang qi is not flourishing, guizhi warms the middle and frees the channels, fuzi warms the yang and expels dampness — strengthening the spleen and stomach. The amount of fuzi is adjusted up or down according to the patient’s degree of cold or heat.
• Yitang (maltose) — sweet and warm; tonifies the insufficiency of the spleen. Maltose is made from boiled grain; it is sweet and enters the spleen channel; and it is very sticky, which holds the decoction in the stomach — it keeps the medicine from rushing downward, letting it work slowly against the stomach wall.

💬 Note from Doctor Luo: Never underestimate this sugar! I have tried it myself — drink the formula without the maltose and the effect really is poor; add the maltose and the effect appears immediately. It both tonifies deficiency and lets the decoction linger in the stomach. This herb cannot be omitted.

• Shengjiang and dazao — pungent, sweet, and greatly warm; generate the ascending and fermenting qi of the spleen and stomach, move the nutritive and defensive qi, and also ease acute tension (huan ji). Shengjiang (fresh ginger) is pungent and warm, helping guizhi and fuzi warm the yang and the spleen and stomach; dazao (red dates) nourishes the blood, adds sweetness, and tonifies the spleen and stomach. Zhang Zhongjing used ginger and dates in many formulas — they are excellent for the spleen and stomach.

💬 Note from Doctor Luo: Look at what is most brilliant about this formula: on one side it warms the middle, on another it tonifies the spleen and stomach, and it also sends shaoyao to soften and restrain the liver and soothe the liver channel, while guizhi itself also has the function of soothing the liver and moving qi — tonifying the spleen and stomach and regulating the liver channel at the same time. This is an extremely important idea Zhang Zhongjing left to later generations, and when we later generations regulate spleen-stomach disorders, we basically all follow this thinking.

The result: one liang per dose, cured after the second dose

How did it go? The case record says: mei fu yi liang, yi fa shui jian, fu er yu — one liang per dose, decocted in water as instructed, and cured after taking it.

💬 Note from Doctor Luo: “Fu er yu” — strictly speaking, he recovered after the second dose; it could also be read as two or three doses. Whether this kind of formula can deliver results, we have direct experience: after taking Huangqi Jianzhong Tang, basically the stomach pain resolves; for illnesses like stomach ulcer, a few doses bring great relief, and then gradual recovery. It is an especially good formula for regulating spleen-stomach disorders.

What to take away: two lessons that still apply today

Lesson one: when the face or body shows a blue tint, first think of the emotions.

💬 Note from Doctor Luo: Inspection (wang zhen) is an important part of Chinese medicine diagnosis. Sometimes everyone’s faces look much the same, but under certain lighting, at a certain angle, you will notice that someone’s face shows a faint blue tint. Whenever the face carries a blue tinge, you should ask: how is this person’s mood? Under pressure lately? Angry? You need to soothe the liver (shu gan). I see it in children too — some children have a faint blue ring around the nose and mouth; such children are almost always emotionally distressed — pressure at home, quarreling parents, a bad atmosphere in the household. Some rural women show a blue cast on the face, often because of unhappy family relations, feeling wronged. So a blue tint somewhere on the face is mostly connected to constrained liver qi and the emotions — this is one key point of diagnosis.

Lesson two: when regulating the spleen and stomach, do not stare only at the spleen and stomach.

💬 Note from Doctor Luo: The spleen and stomach belong to earth; earth is connected to wood and also to water. When you regulate the spleen and stomach, you must not think only of cold and heat in the spleen and stomach — you must also think of the related viscera: if the person is emotionally distressed, it is mostly constrained liver qi running sideways and overwhelming the spleen-earth — so while you regulate the spleen and stomach, you must also think of soothing the liver qi and calming the liver-wood. Only then can you truly regulate the spleen and stomach well. The “tonify the earth” (bu tu) school of Doctor Li Dongyuan and Doctor Luo Tianyi considered problems with exceptional care and left later generations a wealth of experience. The source of this theory is Zhang Zhongjing, and the first generation to apply it in recorded case histories was Doctor Li Dongyuan and Doctor Luo Tianyi — the earliest application records we can see today are right here.

Case source: Weisheng Baojian (Precious Mirror of Hygiene), medical case of Doctor Luo Tianyi (case title: a successful treatment of spleen-stomach deficiency cold with liver wood overwhelming the spleen); commentary based on public lectures by Doctor Luo Dalun (PhD in TCM diagnostics, Beijing University of Chinese Medicine).