Coughing Up Blood, Chest Fullness and Constipation? Doctor Wu Jutong’s Phlegm-Fluid Retention Case Treated with Modified Xiao Qing Long Tang (Minor Green Dragon Decoction)

What the patient was searching for: coughing up blood / chest fullness / can’t catch a full breath / dry stools / cough much worse at night / blood in the sputum with every cough Medical terms: phlegm-fluid retention (tan yin) · lung qi failing to descend · damp-phlegm in the middle burner · external cold with internal fluid (the lung and the large intestine are paired, biao li)

Opening: in the dead of winter, a patient who coughed until he spat blood

On the ninth day of the second lunar month in the ninth year of the Daoguang reign (1829), the end of winter and the beginning of spring, the cold was still biting. At just this time, Mr. Wang, 45 years old, came to see Doctor Wu Jutong (吴鞠通) — his illness had already dragged on for over ten days: coughing, a chest that felt stuffed and full, shortness of breath, and spontaneous sweating. At night the cough grew worse, and the sweating heavier. And the most alarming thing of all: as he coughed, the sputum was streaked with blood.

💬 Note from Doctor Luo: Doctor Wu Jutong was the great Qing-dynasty warm-disease specialist, the author of the Systematic Differentiation of Warm Diseases (《温病条辨》); Angong Niuhuang Wan (Bezoar Resurrection Pill) and Yin Qiao San (Honeysuckle and Forsythia Powder) were both his creations. Everyone assumes he only excelled at warm diseases — but his command of the Treatise on Cold Damage (《伤寒论》) was every bit as deep as anyone’s. One look at today’s prescription proves it.

Who was this patient, and how sick was he?

Mr. Wang, 45, was past the prime of middle age. Symptom by symptom:

• Cough with chest fullness — he coughed without stop, his chest stuffed and distended;
• Shortness of breath — he always felt he couldn’t draw a full breath;
• Spontaneous sweating, worse at night — he sweated lightly on his own, and especially at night;
• Dry stool — he hadn’t moved his bowels in days;
• Blood in the sputum — when the cough was severe, blood came up with it; this was the most frightening symptom of all.

Doctor Wu Jutong felt the pulse: all six positions were wiry (xian) and slightly tight (jin) — the pulses at both wrists felt like taut lute strings, with a touch of tightness.

💬 Note from Doctor Luo: Aggravation at night is a sign of insufficient yang qi — at night yin qi prevails, yang qi weakens further, and the illness intensifies. And “all six pulses wiry” is meaningful too: a wiry pulse indicates phlegm-fluid retention. The moment a master physician touches the pulse, half the diagnosis is already in his mind.

Blood does not always mean heat — the most critical stroke in this whole case

By the usual line of reasoning, blood in the cough mostly means heat breaking the blood into reckless movement — a heat condition — so the natural reflex is to cool the blood and stop the bleeding. But Doctor Wu Jutong said: this must not be treated as a heat condition.

He explained that this was phlegm-fluid retention (tan yin) — the body’s fluids had not been expelled; yang qi was insufficient, so water gathered in the body and slowly congealed into phlegm. This was not consumptive depletion (xu lao), and it must not be treated with the kidney-nourishing, yin-nourishing approach. Instead it required warming yang. The treatment strategy: warm and free the yang qi, spread and open the lung qi, harmonize the spleen and stomach, and transform the phlegm-fluid.

💬 Note from Doctor Luo: This is the single most important point in the whole case. When someone coughs up blood, nine doctors out of ten reach for blood-cooling, blood-stopping herbs — but with phlegm-fluid entrenched in the body, the blood can never be stopped. Doctor Wu Jutong read the true root of the disease from the pulse alone. This skill of not being led around by the symptoms is precisely the dividing line between a master physician and a mediocre one.

Why was the stool dry too? — the lung and the large intestine are paired (fei yu da chang xiang biao li)

Mr. Wang had one more striking feature: up above, coughing, wheezing, blood; down below, dry stool. How could those two things possibly come together?

Doctor Wu Jutong laid it bare: the lung and the large intestine are paired (biao li) — the organs are connected. When lung qi is blocked and will not descend, the large intestine follows and becomes blocked too; conversely, when the large intestine is dried out, the lung qi tends to get into trouble as well — the two feed each other. So the treatment is simple: open the lung qi, and the large intestine will clear on its own — there is no need for rhubarb (da huang) or mirabilite (mang xiao), those violent purgatives; open the upper part and it is done.

💬 Note from Doctor Luo: This is a principle worth remembering for life: when the upper part is blocked, the lower part is blocked too. Open the lung qi above and the stool below passes by itself. Chinese medicine treats disease by “clearing the source so the current flows freely” (shu qi yuan er chang qi liu) — not by attacking every blockage wherever it happens to sit.

Anatomy of the prescription: the “shapeshifting” of Xiao Qing Long Tang — ma huang traded for ma huang gen

The formula Doctor Wu Jutong wrote was a modification of Xiao Qing Long Tang (Minor Green Dragon Decoction). Xiao Qing Long Tang is the famous Treatise on Cold Damage formula for “external cold with internal fluid” — cold attacks from outside while water-fluid (especially in the lungs) gathers within, producing cough, wheezing and palpitations. The formula warms and transforms the water-fluid, and its results are excellent. Herb by herb:

• Yun fu ling (Yunnan poria), 6 qian (about 18 g) — Yunnan is the genuine, Dao-di producing region for poria; it drains the water-damp and phlegm-fluid of the middle burner;
• Gui zhi (cinnamon twig), 4 qian — frees the yang qi; bai shao (white peony), 3 qian — astringes and nourishes yin. Gui zhi warms and frees, bai shao astringes yin: the two form a pair that harmonizes the nutritive and defensive (ying-wei) — the approach of Gui Zhi Tang (Cinnamon Twig Decoction);
• Ban xia (pinellia) — transforms phlegm, drains dampness, harmonizes the stomach and intestines, letting stomach qi move downward;
• Xing ren (apricot kernel) — opens the lung qi and sends it downward, unblocking the congested lungs;
• Wu wei zi (schisandra) — astringent; since cough and wheeze are qi rushing upward, it gathers the qi of the five organs back down;
• Xi xin (asarum) and gan jiang tan (dried ginger charcoal) — the backbone of Xiao Qing Long Tang (xi xin, wu wei zi, gan jiang); dried ginger warms the middle, and phlegm will not transform without warmth — congealed cold-phlegm must be melted by warming herbs;
• Ma huang gen (ephedra root) — the most brilliant move of all! The original Xiao Qing Long Tang uses ma huang (ephedra) to spread and release the exterior. Here the exterior cold was not prominent, so Doctor Wu Jutong swapped in ma huang gen, which does the opposite — it astringes and checks sweating, exactly treating his spontaneous sweating;
• Guang chen pi (aged tangerine peel) regulates lung qi; xiao zhi shi (small immature bitter orange) frees the stool and moves qi; zhi gan cao (honey-fried licorice) harmonizes the whole formula.

Even the decoction method was particular: six large cups of gan lan shui (sweet running water) decocted down to two cups, three doses by day and one by night — four servings spread across the day.

💬 Note from Doctor Luo: The genius is in the ma huang gen. Ma huang disperses outward; ma huang gen astringes and checks sweat. One character’s difference, and the actions are exactly opposite — this is the “transformation” of Xiao Qing Long Tang. The formula also secretly contains Er Chen Tang (Two Matured Ingredients Decoction: ban xia, chen pi, fu ling, gan cao) — the ancestor formula for transforming phlegm — attacking the phlegm from both inside and out. Doctor Wu Jutong also quoted the Huang Di Nei Jing: “When the nine orifices are obstructed, it originates from the stomach and intestines” — problems with the eyes, ears, nose and throat, the “nine orifices,” almost always trace back to the gut. That is why he used ban xia to send stomach qi down and zhi shi with chen pi to open the pylorus (you men), letting the fluids travel downward: once the spleen and stomach are harmonized, the phlegm-fluid has a way out. The suppleness of his prescribing lives entirely in these adjustments.

One round of medicine: the blood stopped, the wheeze and fullness were cured

After taking this formula, the blood-spitting and the wheezing-fullness were cured, and the cough improved by six or seven tenths. On the tenth day of the month (the next day), he took one more dose of the same formula. By the 11th, the patient had a bit of pain on both sides of the head — that was a problem of the shaoyang gallbladder collateral (dan luo), so Doctor Wu Jutong opened a separate formula to clear the heat of the gallbladder collateral, without touching the middle and lower burners, and the headache quickly settled.

Now the pulse: all six positions deep and wiry, with a little cough, shortness of breath and spontaneous sweating remaining, plus a yellowish face and slight swelling of the limbs. Someone asked: shouldn’t we now nourish yin and clear heat? Doctor Wu Jutong answered flatly: “There is absolutely no principle of nourishing yin to assist the evil” — the patient still showed pure phlegm-fluid signs, so he continued transforming the phlegm-fluid with warming herbs in harmony: gui zhi mu (cinnamon twig wood) with bai shao (the Gui Zhi Tang approach), xing ren 3 qian, ma huang gen 3 qian, gan jiang 3 qian, jiang ban xia (ginger-processed pinellia), guang chen pi, zhi gan cao and xiao zhi shi — decocted to three cups, taken in three portions.

💬 Note from Doctor Luo: The original text says “taking this formula for four days,” but I suspect it should read “four servings” (si fu) — three by day and one by night, finished in a single day. The formula was opened on the 9th, another dose on the 10th, and by the 11th we were already at the third visit. Once the phlegm-fluid was transformed, the blood naturally stopped. And the third visit still held to “treat with warming herbs in harmony,” because the phlegm-fluid had not yet been fully cleared — at this moment, anyone who dared to nourish yin or clear heat would be feeding the enemy.

The finishing touch: gan lan shui — the “living water” of the ancient pharmacists

There is a supporting character in this formula worth mentioning: gan lan shui (sweet running water). This was a water used for decocting medicine in ancient Chinese medicine, described by Zhang Zhongjing in the Treatise on Cold Damage. How was it made? Take long-flowing water — water from a stream, a river, a great river — put it in a basin, and keep scooping it up and tossing it high with a ladle, over and over, countless times, until five or six thousand tiny beads of water float on the surface, rolling and bobbing — then it is ready.

💬 Note from Doctor Luo: Some people have actually tried this at home and never saw five or six thousand beads no matter how long they tossed — so what is going on? Actually the ancients’ principle is very plain: water that sits still is in one state; water that keeps flowing and colliding is in another — the molecular chains, the oxygen content, the trace elements are all different. The ancients were “activating” the water. Modern research has found that water left standing gradually produces trace nitrites — after one day a little, and after 20 days the amount can approach 0.7 milligrams. So if a bottle of mineral water has sat for a month, don’t drink it straight — shake it first so the water moves again. Someone has even talked about inventing a “gan lan shui machine” — I think that is genuinely a small invention worth tinkering with.

The great wisdom hidden in dietary taboos: no raw or cold food, no pork, no crab

During the course of the medicine, Doctor Wu Jutong was explicit about dietary restrictions: avoid raw and cold foods — if you are warming the yang while eating cold things that wound the yang, the warming is wasted; avoid pork — pork is rich and greasy and easily feeds phlegm-fluid, and its nature is cool (beef, mutton and chicken are warm; duck and pork are cool); avoid shellfish, seafood and crab — these too are cool in nature.

💬 Note from Doctor Luo: This was Doctor Wu Jutong’s own hard-won experience. Anyone taking warming-yang medicine should remember these three prohibitions so the medicine’s effect is not discounted — if you are transforming phlegm-fluid while eating greasy, raw and cold foods, the phlegm will never finish transforming.

Why don’t the master physicians’ case records ever say “he was finally cured”?

Careful readers will notice that this case ends at the third visit — was the patient ever cured? In fact, case records like this are everywhere in Wu Jutong’s Case Records: first visit, second visit, third visit; some warm-disease cases even run to a tenth, eleventh or twelfth visit over two months of treatment, and yet “how it was finally cured” is often left unwritten. Why?

💬 Note from Doctor Luo: Because the master was too famous — his case records were written so that others could study his way of thinking. Once the thinking is given to you, learning it is the profit. Closing the pen the moment the situation is stabilized is precisely the hallmark of Qing-dynasty case records. In this case, the blood-spitting stopped and the wheezing-fullness was cured; what remained — a bit of cough, a yellowish face, slight swelling — was a matter of slow adjustment. The root of phlegm-fluid lies in a weak spleen and stomach, so the next step is to strengthen the spleen and drain dampness, taking medicine over the long term — half a year, a full year — before the body can truly be healthy.

In northern winters, people like Mr. Wang are especially common — catch a little cold and the cough never ends, the tongue coating white and thick, phlegm-fluid entrenched in the middle burner. Learn from Doctor Wu Jutong: warm and transform the phlegm-fluid, open the lung qi — drain off this load of “water,” and the cough and wheeze above and the constipation below are all released together.

Compiled from Doctor Luo Dalun’s commentary on the case records of Wu Jutong; the case itself comes from Wu Jutong’s Case Records (《吴鞠通医案》).