Swollen Belly and Body, No Urine? Doctor Wu Jutong’s Case of Severe Abdominal Distension (Carp Soup First, Then a Huge Dose of Ephedra to Sweat)
What the patient was searching for: belly swollen huge / whole body swollen / cannot urinate / belly big as a drum / cannot hear / cannot see / spitting blood clots Medical terms: gu zhang (drum-distension) · ascites of cirrhosis · water distension (shui gu) · liver-spleen disharmony · kidney deficiency with failure of qi transformation
Opening: a thirty-two-year-old man in his prime, lying in bed waiting to die
Today we continue with the medical cases of Doctor Wu Jutong (吴鞠通). His given name was Tang, his courtesy name Jutong, and he came from Huai’an, Jiangsu Province — the leading figure of the Qing-dynasty Warm Disease school, whose book Wen Bing Tiao Bian (Systematized Identification of Warm Diseases) made his name famous across the empire. Today’s story is a case record written by Doctor Wu himself, in the first person, in remarkable detail — he said it was one of the most brilliant treatments he had ever witnessed in his life.
The patient, surnamed Chen, was thirty-two years old — a man in the very prime of life. Yet on the fourth day of the second lunar month in the jiayin year (1794), he lay in bed in mortal danger: his belly was swollen huge, as if he were pregnant; his ears could not hear and his eyes could not see; and from his mouth he kept spitting up blood clots, mouthful after mouthful. The physicians who had been called in all shook their heads — not one dared prescribe.
💬 Note from Doctor Luo: This disease is called gu zhang (drum-distension) in the old books — the same family of illness we now call ascites of cirrhosis. Underneath the belly wall it is not simply water: it is water, blood, and even worms piled together. The belly swells larger and larger, and blue veins stand out one by one — it is extremely dangerous. When Doctor Wu Jutong saw this patient, even he was startled, and dared not use medicine rashly. Just imagine — if even a Warm Disease master was that frightened, you know how terrifying this disease is.
Who was the patient, and where did the disease come from?
This illness was not contracted in a day or two. Doctor Wu Jutong always asked about the cause first — and before falling ill, the patient had been in low spirits for a long time, suppressing a fire of frustration, with stagnation of liver qi (gan qi yu jie).
💬 Note from Doctor Luo: Remember — this disease, gu zhang, very often comes from "qi." When the emotions are blocked and the liver qi cannot flow, the liver wood grows sideways and attacks the spleen and stomach — this is what Chinese medicine calls gan mu heng ni ke pi tu — the liver wood attacking the spleen earth. Once the spleen and stomach weaken, water-dampness can no longer be transformed and moved. So this patient had two things happening at once: the spleen could not distribute essence (pi bu neng san jing), so fluids could not reach where they belonged; and the liver could not dredge and discharge (gan bu neng shu xie), so the qi mechanism was blocked — squeezed from both sides, his belly slowly swelled up. And there was a special feature to his swelling: it began at the head and face — in the morning his eyelids swelled first, then the face, then the whole body, and only at the end did the belly distend.
The Nei Jing (Inner Canon) says: "When taiyin (the spleen) is at fault, it develops into gu zhang" — the spleen governs the distribution of essence; it is the spleen’s job to carry fluids and nourishment to the whole body. Now that the spleen was diseased and could not distribute, fluids could not be sent out; "earth swells into a mound" (tu yue dun fu) — everything jammed up in the middle, and the belly distended. It also says: "When jueyin (the liver) is at fault" — the liver governs dredging and discharging; with the liver failing, wood encroached on the earth’s position and the spleen and stomach grew weaker still. In this patient, both conditions were fully present.
How dangerous is gu zhang? A belly full of blue veins, like a spider’s web
Doctor Wu Jutong pointed out that this was not ordinary edema. In ordinary edema the swelling is water — that is still manageable; in gu zhang, water and blood are piled up together, and in ancient times some gu zhang patients genuinely had worms living in their bellies. Some of today’s abdominal tumors and cirrhosis ascites belong to this family — the root is accumulated slowly over a long time, not in a day or two.
How do you tell them apart? Doctor Wu Jutong said one crucial sentence: "How do I know? The whole belly stands out in blue veins, like a spider’s web" (he yi zhi zhi? man fu qing jin bao qi, ru zhi zhu wang). The patient’s belly was covered with blue veins standing out one by one, as clear as the lines of a palm — a terrifying sight. This is called zhi zhu zhang (spider-belly distension), also known as gu zhang (worm-distension) — the character gu is a worm (虫) over a vessel (皿). Doctor Wu said: these are not the "sinews" of the flesh — they are xue mai ning qi — congealed and stagnant blood vessels: the blood had congealed inside the vessels and pooled in the belly, which is why such blue lines stood out.
💬 Note from Doctor Luo: Go to a hospital today, and with cirrhosis ascites patients you will see exactly this — a hugely distended belly covered in blue veins. It is very easy to recognize, and very, very dangerous. Doctor Wu Jutong took one look and knew this was gu zhang, not ordinary edema — the treatment approach is completely different. He stated the principle for treating gu zhang: xing taiyang zhi yang, xie jueyin zhi yin — activate the yang of the taiyang (bladder) and drain the yin of the jueyin (liver) — open a passage upward by promoting sweat so water leaves from above; and drain water downward, putting the lower part in order, dissolving the water-dampness bit by bit.
How did the previous physician make it worse? Gui Fu Di Huang Wan plus oyster — sealing off all the yang
Before coming to Doctor Wu, the patient had seen another doctor. That physician mistook the illness for ordinary edema and prescribed Bawei Wan — the Eight-Ingredient Pill, that is, Gui Fu Di Huang Wan (Cinnamon-Aconite Rehmannia Pill), with a heavy addition of oyster (mu li) to astringe and hold the yin. The result? Yang qi could no longer circulate, and the congealed yin grew worse by the day — the more he treated, the worse the patient became.
So the patient’s pulse at all six positions was deep, wiry and thin; his ears went deaf, his eyes went blind; he lay bedridden, and blood clots kept bubbling up from his mouth. Even the physician could see the crisis — he dared not prescribe any more.
💬 Note from Doctor Luo: This is the lesson of mistreatment (wu zhi). Gu zhang is a case of yang qi trapped by cold-dampness and blood stasis — yet the doctor went and tonified the yin and astringed the yin: Gui Fu Di Huang Wan is full of yin, soft herbs like cooked rehmannia, and oyster is an astringent that collects yin — it was like pressing the little yang that remained further down and pulling it back in; the yin congealed still more, and the blood froze solid. That is why the Nei Jing speaks of xue mai ning qi — the blood congealing inside the vessels — the blood could no longer move. By the time the illness reached this stage, even Doctor Wu Jutong dared not prescribe suddenly, afraid that one wrong move would finish the man off.
Doctor Wu’s first move: before any medicine, drink carp soup
Doctor Wu Jutong thought it over: at this stage, prescribing strong medicine immediately carried too much risk — so he opened with food therapy. He used a very famous formula — Qianjin Liyu Tang (the Thousand Gold Carp Decoction).
💬 Note from Doctor Luo: This formula comes from Sun Zhenren — that is, Sun Simiao — in his Qianjin Fang (Thousand Gold Prescriptions). Sun Simiao’s original formula: carp plus baizhu, fuling, shaoyao, danggui and shengjiang, ground into powder and boiled into a carp soup — it was used for edema and difficult urination in pregnant women, and it was very good at promoting urination. Doctor Wu Jutong simplified it: carp alone, without the other herbs. And he had his own theory — the most yang, the most supremely spiritual creature is the dragon (long); the dragon governs water and can move water — but where do you find a dragon? The answer: the carp can turn into a dragon — the old legend says that a carp that leaps the Dragon Gate becomes a dragon, so the carp shares kinship with the dragon, and its power to move water is the most spiritual of all. That is the ancients’ imagination — but in practice it really works.
How do you cook it? Doctor Wu said: take one live carp — a big one, six jin in weight — do not scrape off the scales, do not open the belly, leave the organs inside; add one jin of scallion and one jin of ginger, boil thoroughly in water; then add one jin of vinegar, and drink the soup.
Within a single day and night of drinking it — his ears could hear again, his eyes could see again, exactly as before; the blood clots from his mouth were all gone, and his spirit was clear and refreshed! Only the belly was still distended.
💬 Note from Doctor Luo: Why did it work so fast? Because inside gu zhang there is a great deal of water, mixed with stagnant blood, creating enormous pressure — the pressure crushed the orifices above: eyes and ears are orifices, and the water pressure had disabled their function. When the carp soup went down, the water lessened, the pressure dropped, and the orifices recovered — and the blood clots stopped coming. You see — food therapy, used correctly, works faster than medicine. Doctor Luo Dalun says that after he studied this case, whenever he met similar patients, he recommended the carp soup to many people, and the results really were quite good.
The fifth day: the illness came from above, so treat it from above — two liang of ephedra!
The carp soup was taken on the fourth day; by the fifth day, the belly was still large. What next?
Doctor Wu Jutong cited the Nei Jing principle: "When the illness starts below but flourishes above, treat the below first; when it starts above but flourishes below, treat the above first." This patient’s swelling had started above — from the head and face — so the right move was to promote sweat first (dang xian fa han), driving the water out through the skin.
So he wrote the prescription: Mahuang Fuzi Gancao Tang — the Ephedra, Aconite and Licorice Decoction — a formula of Zhang Zhongjing, with just three herbs: mahuang (ephedra), fuzi (prepared aconite) and zhi gancao (honey-fried licorice). Decoct it into five bowls; first take half a bowl; the moment sweat appears, stop — do not take more; if no sweat, take again, stopping only when sweat comes — this is Zhang Zhongjing’s method of taking medicine: the whole dose is not poured down at once.
But the moment the amounts were written down, everyone in the room exploded: ephedra two liang! prepared aconite one liang six qian! honey-fried licorice one liang two qian!
💬 Note from Doctor Luo: Two liang of ephedra is 60 grams! Which physician today would dare prescribe that? Every doctor present was terrified. But Doctor Wu Jutong knew exactly what he was doing — this patient’s yin cold was too fierce, the yin murk too heavy, the qi mechanism had been closed off for too long — his worry was not that the ephedra was too much, but: even two liang of ephedra might not produce a single drop of sweat!
The famous scene: Mr. Chen declares "absolutely no effect," and Doctor Wu predicts the dosage to the last fen
The formula had just been written — the amounts not yet filled in — when a Mr. Chen (himself a physician) who was standing nearby spoke up: "Absolutely no effect!" — this formula is useless, I’ve used it before!
Doctor Wu Jutong answered calmly: "If you used this formula, of course it had no effect. If I use it, of course it will work."
Another gentleman, a Mr. Wang (surname Wang; his given name is forgotten), was puzzled: same formula, just three herbs, not one more, not one less — why would it work in your hands and not in mine? Surely these ignorant plants and trees do not obey your command?
💬 Note from Doctor Luo: This scene is too brilliant. Doctor Wu Jutong started "fortune-telling." He said: Mr. Chen, you are honest and kind by nature, and timid — you always prescribe cautiously. Fearing that ephedra sweats too violently, you would certainly use only eight fen (less than one qian); afraid that aconite is too drying, you would use one qian of it to check the ephedra; and worried that both are too fierce, you would hold them down with licorice, so you would use licorice one qian two fen. With such tiny amounts, the patient would not sweat in a whole day of drinking — then you would get anxious and switch to the Eight-Ingredient Pill — that medicine is soft and yin, so you felt bold enough to use it in large doses.
Sitting there was also a Mr. Chen Mengshan, who loved a good show. He immediately ran into the patient’s room and dug out the prescription that Mr. Chen had written a few days earlier — and when he brought it out and compared, the amounts matched to the very fen: ephedra eight fen, aconite one qian, licorice one qian two fen! The six or seven physicians present all burst out laughing: "Master Wu, can you do divination? How did you know the amounts he prescribed?"
Doctor Wu Jutong said: Mr. Chen and I often make house calls together — when a patient invites one, he invites us both, and we see patients side by side every day — I know him too well. When he writes a formula, he is bound to write it this way.
Why dare to use two liang of ephedra? Let the ephedra take the lead!
So how did Doctor Wu himself prescribe? Ephedra two liang, prepared aconite one liang six qian, honey-fried licorice one liang two qian — the moment the amounts were written, the six or seven physicians in the room made an uproar again: "Are you mad! Who uses ephedra like that?"
But Mr. Chen stepped forward and said: "No harm — if anything goes wrong, I will personally vouch for it!" The others said: "Shut up! You yourself did not dare use a full qian — you used eight fen — yet you dare vouch for a man prescribing two liang?" Mr. Chen said: I have seen Master Wu’s skill with my own eyes. Years ago at Master Juxi’s place, Doctor Wu treated a case of postpartum faintness and oppression (chan hou yu mao), prescribing two qian of danggui; Doctor Wu criticized it on the spot: danggui is the qi-moving herb within blood — it is the most capable of stirring up yang; after childbirth, with yin deficient and blood depleted, the yang qi is already floating upward — using two qian of danggui is too much! If two qian of danggui was too much for him, then when he now prescribes two liang of ephedra, he must have his reasons — that is why I dare to vouch for him.
💬 Note from Doctor Luo: What was Doctor Wu’s own reasoning? He said: why do people fear ephedra like a tiger? Because using too much ephedra causes profuse sweating, and they fear yang collapse (wang yang) — the yang qi scatters all at once and the patient dies. But through the ages, there has never been a case of "yang collapse without sweating"! If no sweat comes out, how could the yang be lost? Yang collapse always comes from sweating in torrents. Our method is "take half a bowl first; the moment sweat appears, stop" — the moment sweat comes, we withdraw. What is there to guard against? What is there to fear? What is truly to be feared is that the yin murk is too heavy and the qi mechanism has been closed too long — even two liang of ephedra may not produce sweat. If I come again tomorrow and no sweat appears, I will sweat him again tomorrow.
The medicine-buying commotion: the pharmacy refused to sell, so the master of the house went himself
The patient’s family took the prescription to the Xianzhi Tang pharmacy to buy the herbs — and the pharmacy refused to sell! They said the prescription must have been written wrong: it must be two qian of ephedra, not two liang! If anything happened from taking this, who would bear the responsibility?
The servant went to buy it — refused. The master of the house went in person, saying: this is a prescription by Doctor Wu Jutong — a prescription by a famous physician — and only then did they agree to weigh out the herbs.
They brought it home and he drank half a bowl — two liang of ephedra, and not a single drop of sweat!
The sixth day: all the physicians pronounced a death sentence; Doctor Wu produced a stroke of genius
On the sixth day, the physicians all gathered (the family must have been fairly wealthy — they had invited six or seven doctors at once). They looked at the situation: two liang of ephedra, and still no sweat! They all said: "No sweat means death; this case cannot be saved" (han bu chu ze si, ci zheng bu ke wei) — this man cannot be rescued.
Doctor Wu Jutong said: "Not so" (bu ran). If this were truly a fatal case, the carp soup would not have worked. The fact that it worked shows this man still has vitality. What to do? He used Zhang Zhongjing’s method of taking Guizhi Tang — Zhongjing used congee to support the stomach qi and induce a light sweat; Doctor Wu Jutong used carp in place of congee: buy another live carp, four jin in weight, cook it by the same method into carp vinegar soup. Then: drink one bowl of the ephedra decoction, and immediately drink one bowl of the carp soup — exactly the same principle as sipping hot congee after Guizhi Tang — except that Zhongjing’s congee supported the stomach qi, while Doctor Wu’s carp soup supported the metabolism and movement of water fluids.
And then, something miraculous happened:
💬 Note from Doctor Luo: Remember this sequence — drink one bowl, sweat reaches the eyebrows; drink again, the upper eyelids sweat; drink again, the lower eyelids sweat; drink again, the nose sweats; drink again, the sweat reaches the upper lip — the sweat moved from the top down, bit by bit! Two packets of the medicine meant four liang of ephedra, plus a pot of carp soup, all drunk within one day and night — the sweat reached past the knees. Now look: the swelling above the navel was completely gone! The face was gone too — only the belly was still large. Tell me, is that not divine?
Sweat coming out bit by bit — is that real? Doctor Luo has seen it
You may think this sounds mystical — sweat appearing bit by bit at the eyelids, the nose, the lips? Doctor Luo Dalun says: I have seen exactly this with my own eyes.
💬 Note from Doctor Luo: I know a Mr. Zhong Wenhui, a descendant of a famous medical family, who sees patients at a hospital in Beijing. He treats Guillain-Barré syndrome patients — the kind who waste away to skin and bone from muscle atrophy. He regulates and nourishes them gradually — and how does the flesh grow back? It starts at the hands and grows upward, inch by inch! The line between where flesh had grown and where it had not was sharp and clear, like a cliff — the flesh filled in step by step like that. If you have never seen it, you could not imagine it. I myself once treated a child whose body hair had all fallen out — eyelashes, scalp hair, downy hair — everything. When we nourished him, how did the hair come back? First one eyebrow grew in, while the other side showed nothing; with a little more nourishment, the other side filled in. It really does start on one side and grow little by little. So when Doctor Wu Jutong wrote "the sweat came out bit by bit," it is true — the body’s recovery often proceeds in exactly this orderly fashion — it is truly wondrous.
The seventh day: swelling below the waist — promote urination — Wuling San
The sweat had reached the knees, and all the swelling above the navel was gone. But the Nei Jing says: "If the sweat does not reach the feet, the patient cannot yet be considered out of danger" (han chu bu zi zu zhe si). The patient’s lower body was still swollen — water is yin in nature and travels downward. What to do? When the swelling is below the waist, promote urination (Jin Gui Yao Lue principle).
Doctor Wu Jutong switched to Wuling San — the Five-Ingredient Powder with Poria — Zhang Zhongjing’s formula: zhuling (polyporus), fuling (poria), guizhi (cinnamon twig), zexie (alisma) and baizhu (atractylodes). Here Doctor Wu replaced the cinnamon twig with cinnamon bark (rougui). He prescribed it for fifteen days — from the sixth day to the twenty-first — taken every single day; after fifteen days, the illness neither improved nor worsened, and not a single drop of urine came out (xiao bian juan di bu xia)!
Mr. Chen Mengshan grew anxious: Old Wu, your ephedra worked like magic before — how is it that now not a single drop of urine comes out? Change the formula, quickly!
Doctor Wu Jutong replied: "When the disease does not respond, the medicine is not fine enough" (bing zhi suo yi bu xiao zhe, yao bu jing liang) — it is not that the formula is wrong; it is that the medicine is wrong! Go and buy cinnamon of especially fine quality; if what you bring back is the same grade as before, tomorrow I will not be able to write a prescription at all.
💬 Note from Doctor Luo: Remember this sentence — "When the disease does not respond, the medicine is not fine enough." Whether the formula is right is one question; the quality of the medicine is another. Genuine Dao-di herbs and ordinary herbs differ in nature as heaven from earth. Doctor Wu Jutong insisted the formula was fine and the problem lay in the origin and quality of the cinnamon — that is the confidence of an old master.
The power of genuine Dao-di herbs: the moment the Anbian qinghua cinnamon arrived, Doctor Wu smiled
On the twenty-second day, Mr. Chen Mengshan indeed returned with fine medicine — a fresh stick of purple, oily, high-grade Anbian qinghua cinnamon. This is the Dao-di product of Guangxi cinnamon — Anbian cinnamon, so rich in oil that it fairly oozed oil in the hand; you could tell at a glance it was first-rate, and it had cost a good deal of money.
Doctor Wu Jutong looked at it and said one sentence: "With this cinnamon, urine will surely come — but I fear collapse" (de ci gui bi you xiao bian, dan kong tuo er) — with this fine stuff, the urine is certain to flow; only I fear that the patient will urinate so much at once that the upright qi scatters and he collapses.
💬 Note from Doctor Luo: Why is cinnamon so crucial? The Nei Jing says: "The bladder is the official of the state capital; fluids are stored there, and when qi transforms, they come out" (pang guang zhe, zhou du zhi guan, jin ye cang yan, qi hua ze neng chu yi). Whether urine can come out depends on qi transformation (qi hua) — on kidney yang and the fire of the life gate (ming men) steaming and transforming the water. Cinnamon is the number-one herb for warming the kidneys, assisting yang and promoting qi transformation. The earlier cinnamon was not of sufficient quality, the qi transformation would not move, and the water could not come out; with the genuine Anbian cinnamon, once qi transformation recovered, the urine flowed.
Afraid that too much urine would scatter the qi, Doctor Wu added four qian of gui (here he should have used cinnamon twig) to two liang of Wuling San, plus three qian of Korean ginseng (gaoli shen / liao shen) — ginseng tonifies qi and holds the upright qi steady — however much he urinated, there was no fear of collapse.
One night, three and a half big basins of urine: the whole body like an empty cloth sack
Doctor Wu Jutong then gave one more curious instruction: the patient slept on a palm-fiber bed (a bed made of palm fiber), and the family was to boil up three or four big basins and put them under the bed — the urine at night would be tremendous; when the bedding got wet, do not move it — wait until morning to clean up.
At zi shi (midnight) — the hour when yin reaches its peak and the single yang begins to be born — the urine flowed! It came in wave after wave, and only finished in the morning — three and a half big basins in all.
When Doctor Wu came in the morning to look: the patient’s whole body felt like an empty cloth sack (zhou shen ru kong bu dai) — all the water had poured out at once, and his belly sagged like a deflated ball; his skin looked like tiger skin (hu pi) — like the wrinkled belly of a woman after childbirth, folded and loose. From that day on, Doctor Wu Jutong began regulating the spleen and stomach, tonifying gradually — and after a hundred days, the illness was completely cured.
💬 Note from Doctor Luo: Look at the rhythm of this case: sweating above, with the sweat moving from the top down; promoting urine below, with the urine beginning at midnight — above and below, everything was finding an exit for the water-dampness. How to sweat, how to drain — Doctor Wu Jutong had a method and a measure for every step: the dosage, the herbs he matched in — all of it was true skill. The other physicians standing by could barely exchange a word with him; they could only gape. That is what a master looks like — a stroke of genius.
Epilogue: why does a Warm Disease physician’s hands carry the shadow of Shanghan formulas on every side?
At the end, Doctor Luo Dalun walks us through several layers of meaning.
💬 Note from Doctor Luo: First — Doctor Wu Jutong was a Warm Disease physician, yet every formula in this case belongs to the Shanghan lineage — Mahuang Fuzi Gancao Tang, Wuling San, the Guizhi Tang congee-sipping method — all from Zhang Zhongjing. What does that tell you? A person who has truly mastered medicine uses Shanghan and Warm Disease together, both hands at once. It is not that being a member of the Warm Disease school means using only Warm Disease formulas and only cold, cooling herbs — that would leave a piece missing; and the reverse — recognizing only Shanghan formulas and refusing Warm Disease formulas — leaves a piece missing too. Whatever pattern you see, use whatever formula fits — that is what makes a physician complete.
💬 Note from Doctor Luo: Second — where did this gu zhang come from after all? Insufficient upright qi and kidney qi, with failure of qi transformation; plus unexpressed liver qi and emotional stagnation; plus weak spleen and stomach with water-dampness pooling — deficiency, cold, dampness and stasis piled up in the belly, more and more, and the belly grew larger and larger. Some patients genuinely have something wrong inside — cirrhosis, abdominal tumors — which also makes the belly very large. So the lesson of this case is: gu zhang must be looked at through the spleen, the liver and the kidney together; once qi transformation opens, once water-dampness is drained, and then the spleen and stomach are tonified gradually — only then does the disease leave by the root.
💬 Note from Doctor Luo: Third — why is this case record so trustworthy? Every person is named — Mr. Chen, Mr. Wang, Mr. Chen Mengshan — the names are all there; the pharmacy refusing to sell, the master of the house going to buy it himself — these details are written into the record. A fabricator would never dare write so many of his fellow physicians into the story — these doctors would all see it and take him to task. So Doctor Wu Jutong’s account is a completely true first-person record — we use it as a textbook, savor it slowly, and there is much to learn.
That concludes today’s case. Arranged from Doctor Luo Dalun’s commentary on Doctor Wu Jutong’s medical cases; the original case is from Wu Jutong’s Case Records (gu zhang / drum-distension section).
The original case is from Wu Jutong’s Case Records (《吴鞠通医案》, gu zhang / drum-distension section); the commentary is adapted from the public lectures of Doctor Luo Dalun (Ph.D. in TCM diagnostics, Beijing University of Chinese Medicine).