Ten Years Unable to Eat, Seizures at Any Sound? Doctor Wu Jutong’s Case of Liver Constraint (Gan Zhao) and Collateral Disease Treated with Xuanfu Flower Decoction

What the patient was searching for: pain under the ribs / pain in both flanks / convulsions at any sound / suddenly fainting / unable to eat / pain in the liver region Medical terms: gan zhao (liver constraint syndrome) · collateral disease (jiu bing ru luo — chronic illness settling into the collaterals) · gan jue (liver syncope) · liver qi constraint with qi stagnation and blood stasis · hepatic coma

Opening: winter of 1824, a patient everyone thought was beyond saving

On the second day of the eleventh lunar month in the fourth year of the Daoguang reign (Jiashen year, 1824), the great Qing-dynasty physician Doctor Wu Jutong received a female patient, a woman named Yang, 49 years old. In those days 49 was already well into old age — and the sight of her would chill anyone’s heart: skin and bones, at death’s door, lying there twitching and convulsing again and again, unable even to take food.

💬 Note from Doctor Luo: Wu Jutong — personal name Tang, courtesy name Jutong — was from Huai’an, Jiangsu. He was the great Qing-dynasty warm-disease (wen bing) specialist, author of the Systematic Differentiation of Warm Diseases (《温病条辨》), founder of the triple-burner (san jiao) system of pattern differentiation, and the originator of famous formulas like Yinqiao San, Sangju Yin and Sanren Tang. His Case Records are kept in extraordinary detail — every follow-up visit, every change of prescription, all of it recorded. This case is told straight from the original record, with the timeline perfectly clear.

How did this woman Yang fall ill? The record says it in four characters: yin yu xie tong — flank pain from emotional constraint. Because her emotions were unsettled, her liver qi became stagnant: first came pain in both flanks (under the ribs), then nausea and vomiting of food, and eventually it developed into something terrifying: gan jue (liver syncope).

Who was the patient? Ten years unable to eat, convulsing at any sound

Just how severe was the illness by the end? Doctor Luo Dalun says: put this patient in a modern hospital today and even modern medicine would shake its head — end-stage liver disease, at death’s door. Her symptoms, concretely, were these:

• For ten years she had been unable to eat properly — at each meal she could manage only a sip of rice porridge and one small wine-cup of fried rice flour, not a mouthful more;
• The slightest sound sent her into convulsions — if anyone slapped a table or made any noise, she seized on the spot, and each fit took two or three days to slowly settle; sometimes she even fainted outright;
• Amenorrhea for two years — her menses had stopped for two full years;
• Whole-body pain — she ached everywhere, head to toe;
• Phlegm-fluid cough — phlegm and coughing, year-round, without a break;
• Pulse: all six positions stringlike, tight and long — like a taut zither string, both tight and long. A stringlike pulse indicates liver disease; tightness indicates pain and cold; long plus stringlike means the liver qi is not flowing freely and water-dampness has pooled internally.

💬 Note from Doctor Luo: What is gan jue? It is liver qi rushing upward, like an epileptic seizure — the person suddenly faints, vomits, convulses. In today’s language it overlaps to a degree with hepatic coma and similar disorders of consciousness. In Chinese medicine this is a disorder of the spirit caused by liver qi surging upward. A 49-year-old woman, thin as a bundle of sticks, convulsing at any sound, eating one mouthful a day — the family would surely have been in despair. Yet Doctor Wu Jutong actually brought this patient back to life — that is the “resurrection” promised in the title.

Ten years of treatment that only made her worse — because the previous doctors never knew “gan zhao” or “collateral disease”

The illness did not arrive in a day. Over those ten years, the doctors before him had known only how to nourish yin, tonify deficiency and use cooling herbs — yet they never even understood what the disease was called. Doctor Wu Jutong saw it at once and said: the previous doctors did not recognize the treatment for gan zhao and collateral disease — they did not know this was the “liver constraint” syndrome, nor how a “collateral disease” should be treated.

💬 Note from Doctor Luo: What is gan zhao? The name comes from Zhang Zhongjing’s Essentials from the Golden Cabinet (《金匮要略》). Zhongjing said to treat gan zhao with Xuanfu Flower Decoction (Xuanfu Huatang), and he described one wonderfully vivid symptom — “the person constantly wants to step on his own chest” (qi ren chang yu dao qi xiong shang): this kind of patient always wants someone to step on or press their chest — pressing feels good. And when the disease is not yet severe, “she only wishes to drink something hot” (dan yu yin re) — she constantly wants warm drinks. Look how vivid the ancients’ records are!

Gan zhao comes in two types. One is genuine liver disease — liver-heat patterns, damp-heat patterns, what we might roughly call hepatitis today; that is a heat pattern. The other is this woman Yang’s type — liver qi constraint: from anger and bad emotions, the qi gets stuck, the blood also stagnates, qi and blood cannot circulate, and so the region under the ribs and below the sternum becomes distending or stabbing pain; the patient always wants to press and rub the spot to feel better, and this is accompanied by inability to eat, belching, abdominal distension, loose stools, and fatigue. In the qi-stagnation-with-blood-stasis type of gan zhao, liver function tests may even show abnormalities — it is linked to organic liver disease in the modern sense as well.

And what is a “collateral disease”? Chronic illness entering the collaterals (jiu bing ru luo). Ordinary blood stasis blocks the main channels (jing); but when an illness drags on for years, the stagnant blood burrows into the very fine collaterals (luo). The jing channels are the big thoroughfares; the luo are the small branches, like capillaries. Once disease has entered the collaterals, ordinary blood-moving herbs cannot reach it, and the treatment strategy must change.

Zhang Zhongjing’s formula: Xuanfu Flower Decoction — and the “new silk” that scholars have argued about for a thousand years

Doctor Wu Jutong “always sought the root of the disease” and treated it from the angle of gan zhao and collateral disease. The first formula he wrote was built on Zhang Zhongjing’s Xuanfu Flower Decoction — an extremely simple formula: xuan fu hua (inula flower) three liang, scallion fourteen stalks, and a little xin jiang (newly dyed silk). Xuan fu hua and scallion are easy to understand; it is that “xin jiang, a little” that scholars have argued about for over a thousand years.

💬 Note from Doctor Luo: What exactly is xin jiang? Zhang Zhongjing wrote only “a little,” and later generations were left scratching their heads. Through the ages several theories have circulated: some say it is qian cao (madder root) — a blood-moving herb used for dyeing; some say hong hua (safflower) or even Tibetan saffron; some say jiang xiang (Dalbergia heartwood); and many more say it is silk dyed red — in ancient times cloth was dyed with madder, safflower, Dalbergia and similar plants, and in the Hainan region there really was a tradition of dyeing cloth with Dalbergia. Doctor Wu Jutong’s own opinion was “xin jiang sha”: freshly dyed silk fabric that had never been washed. That theory holds a respectable place, because silk itself has medicinal properties — modern research has found that silk has an anticoagulant effect: it moves blood and unblocks the collaterals, and while unblocking the collaterals it can also stop bleeding. Combined with madder — which moves blood, breaks up stasis, regulates qi, stops pain, unblocks the collaterals and cools the blood — you have the perfect pairing for collateral work. Incidentally, Professor Zhao Shaoqin (the great nephrologist of Beijing University of Chinese Medicine) always used qian cao and dan shen in treating kidney disease.

The herb xuan fu hua is also full of subtlety. The ancients said, “of all the flowers, all rise — only xuan fu hua descends” (zhu hua jie sheng, xuan fu du jiang). Every flower’s qi travels upward; only inula flower goes downward — so it can descend qi, transform phlegm, promote urination and stop vomiting. Your liver qi is rushing upward? It presses downward. Exactly what the case calls for.

The prescription unpacked: one collateral-unblocking formula, all “warmth-first”

Doctor Wu Jutong built on Xuanfu Flower Decoction and added his own customary ingredients to make a qi-regulating, collateral-unblocking formula:

• Xuan fu hua (inula flower): descends qi and transforms phlegm; xin jiang sha (newly dyed silk): moves blood and unblocks the collaterals;
• Jiang xiang mo (Dalbergia heartwood powder): regulates qi; guang yu jin (turmeric root tuber): regulates qi and resolves constraint;
• Dang gui xu (angelica rootlet) — the fine root of dang gui: nourishes the blood, and it too unblocks the collaterals;
• Chuan jiao tan (Sichuan peppercorn, charred): peppercorn burned into charcoal — warms the middle burner, regulates the spleen and stomach, enters the kidney channel; charcoal has an astringent, restraining nature yet does not agitate. This is an herb Doctor Wu Jutong used in quantity, while other physicians used it rarely;
• Su zi shuang (perilla seed frost): perilla seeds are crushed and pressed for oil; the pressed residue is the “frost” — it stops cough, calms wheezing and sends qi downward, without the drawback of loosening the bowels. This use is basically Doctor Wu Jutong’s invention: some people have a lax, slipping large intestine — eat anything oily and they immediately get diarrhea. Su zi shuang calms cough and wheezing without loosening the bowels, exactly right for this patient who could not even hold food;
• Gui zhi (cassia twig): warms the channels and unblocks the collaterals; ban xia (pinellia): descends qi and transforms phlegm; qing pi (green tangerine peel): regulates qi and unblocks the collaterals.

💬 Note from Doctor Luo: Look at the structure of this formula — qi-regulating herbs (jiang xiang, qing pi, yu jin) plus blood-moving, collateral-unblocking herbs (xin jiang sha, dang gui xu, gui zhi) — and everything is warm-first, not a single cold herb anywhere. Why? Because the root of the disease lies in anger: qi stagnation and blood stasis are stuck in the collaterals. Treating a collateral disease follows one single line of thinking: regulate the qi, then use blood-moving, stasis-breaking herbs to open up the collaterals. There is a modern counterpart to this scholarship — Academician Wu Yiling of Yiling Pharmaceutical has studied collateral disease and advocates using insect herbs to unblock the collaterals, walking the same road as Zhang Zhongjing; formulas like Da Huang Zhe Chong Wan and Di Dang Tang use insect herbs. But for a liver disease caused by emotion, the treatment must center on regulating qi — you cannot just attack and purge.

A twist in treatment: after seven days, why did he switch formulas?

The more carefully the disease was observed, the more flexibly the formulas were used. The follow-up records are perfectly clear:

• Second day of the eleventh lunar month: first visit; the collateral-unblocking formula was taken;
• Fourteenth day of the eleventh lunar month: after seven days on the previous formula: phlegm-fluid was still copious — lots of phlegm, frequent coughing, poor sleep at night. Doctor Wu Jutong judged: the spleen and stomach were weak and water-dampness too heavy, so he paused the collateral herbs, focused entirely on regulating the spleen and stomach and dispelling water-dampness, and switched to the second formula.

That second formula: ban xia (dries dampness, transforms phlegm), sheng yi ren (raw coix seed) (dispels dampness), zhi shi (immature bitter orange) (moves qi, descends qi, breaks up congealed phlegm-fluid), fu ling (poria) (strengthens the spleen, dispels dampness), dan gan jiang (dried ginger) (warms yang, transforms water-dampness), guang chen pi (aged tangerine peel) (regulates qi), plus gui zhi (cassia twig).

💬 Note from Doctor Luo: There is a fine point of formula study here. Ban xia, fu ling and guang chen pi, with gan cao (licorice), make Er Chen Tang (Two Aged [Ingredients] Decoction) — the ancestral formula for transforming phlegm. Add zhi shi and zhu ru (bamboo shavings) and you get Wen Dan Tang (Warm the Gallbladder Decoction). But Doctor Wu Jutong did not add zhu ru (which clears heat) — he added gui zhi instead. Both formulas transform phlegm, but Wen Dan Tang clears heat; that single herb changes the entire formula into a warm one. Why? “Phlegm will not transform unless warmed” (tan fei wen bu hua). This patient had been ill for ten years; her yang qi was insufficient and spleen yang failing, which is why water-dampness pooled inside and would not transform. You must warm it with gan jiang and gui zhi — once yang qi is roused, the phlegm-dampness can dissolve.

• Twenty-seventh day of the eleventh lunar month: her appetite had opened a little — she could eat half a bowl of thin porridge! But the flank pain remained — so back to the collateral-unblocking formula;
• Fourth day of the twelfth lunar month: the flank pain had settled; now cough predominated — she switched back to the spleen-strengthening damp-dispelling formula;
• Eleventh day of the twelfth lunar month: Doctor Wu Jutong, a man of the Huai region (today’s Huai’an, Jiangsu), was about to travel to Shaoxing. He instructed the patient to take the spleen-strengthening damp-dispelling formula regularly, and the moment the flank pain flared up, take the collateral-unblocking formula immediately — alternating the two. By this point she could eat half a bowl of soft, well-cooked rice — her appetite had truly opened.

Progress and a setback: one and a half bowls of rice, menses restored — then an attack of external evil

By the twenty-eighth day of the second lunar month, 1825, Doctor Wu Jutong returned for a follow-up: the pulse was somewhat calm — still a little stringlike, but stomach qi was present; there was life force. Now she could eat one and a half bowls of cooked rice (Doctor Luo laughs: “that’s a bigger appetite than mine!”) and her menses had returned. Doctor Wu Jutong instructed: continue alternating the two formulas.

But in the third month came a stumble — on the night of the ninth day of the third lunar month, she caught an external evil. She could not rise, could not sit, could not lie down; restless and helpless. Doctor Wu Jutong wrote a formula: Pi Li San (Thunderclap Powder).

💬 Note from Doctor Luo: Pi Li San is an important formula Doctor Wu Jutong used for treating warm plague; its nature is warm and hot, and it works extremely well for this kind of cold-dry external evil, in cases where a warm disease has turned cold. Doctor Wu Jutong was a warm-disease master — treating external contraction was his home turf. One dose, and she was better the next day. This case record is extraordinarily detailed — whatever illness arose in the middle, whatever formula was used, it was all written down. That is what a true case record looks like.

On the eighteenth day of the third lunar month: she could eat two small bowls of cooked rice, and the six pulses had improved another notch. Still the two formulas were alternated.

The final “medicine” was not medicine: two letters became her motto

On the third day of the fourth lunar month, Doctor Wu Jutong set out for Shaoxing again. On the eighth day he reached Suzhou — and he still could not stop worrying about this patient: the illness had been so severe, recovery so slow, he feared she would relapse. So he wrote her a letter, and the letter contained one thing: she must regulate and soothe her temperament (ling qi tiao shi xing qing). Your illness is rooted in bad emotions — you are angry every day and stifled every day; how can the body ever get well? In the fifth month he wrote a second letter, “admonishing her with great principles” (tong yi da daoli kaidao zhi) — earnestly counseling her: life should be open and magnanimous; think things through; what is there to feel so wronged about?

💬 Note from Doctor Luo: Doctor Wu Jutong was a man of fine feeling and great kindness — with the patient out of reach, he still remembered to write and counsel her. He was exceptionally good at “talking the illness out,” at verbal guidance — this he inherited from Zhu Danxi: Zhu Danxi’s clinical method placed great weight on untying the patient’s emotional knots; only when the heart-knot is spoken open does the illness heal quickly. Prescribing medicine without opening the heart — that treatment never finishes the job.

Letters traveled slowly in those days; the reply did not arrive until the tenth month. The reply said: this woman had made Doctor Wu Jutong’s two letters her motto, placed them by her desk, and read one through every single day. She was a sincere patient — a woman at death’s door who had been brought back to life by Doctor Wu Jutong; she truly believed the doctor’s words. And what was the result? Her appetite grew again — two small bowls of rice were no longer enough; her spirits soared; and the whole family rejoiced. The case ended perfectly.

The secret of the resurrection: to treat the liver, you must treat the spleen

Two small formulas — one unblocking the collaterals, one strengthening the spleen and dispelling dampness — alternated back and forth for over half a year, and turned a skin-and-bones liver patient who seemed beyond saving into a woman eating two bowls of rice with soaring spirits. Doctor Luo Dalun sums up the hidden wonder in one sentence of truth:

💬 Note from Doctor Luo: To treat the liver, you must treat the spleen — build up the spleen and stomach, repair them well, and the liver’s recovery is greatly helped. This is an unchanging principle. Why? Zhang Zhongjing said it long ago: “When you see disease of the liver, know that the liver transmits to the spleen, and must first strengthen the spleen” (jian gan zhi bing, zhi gan chuan pi, bi xian shi pi). The wood of the liver overacts on the earth of the spleen — when the liver is ill it most easily transmits to the spleen and stomach — so to treat the liver you must first strengthen the spleen. In this case record, the collateral-unblocking formula and the spleen-strengthening formula alternate back and forth — on one hand soothing and regulating the liver, nourishing blood and unblocking the collaterals, on the other strengthening the spleen and dispelling dampness — both hands working, both strong. That is the soul of the whole case. What should ordinary people learn from it? Soothe the liver, regulate the emotions — and above all, don’t get angry; think things through. When the liver qi flows freely, no illness will come looking for you.

Looking back at this case, the modern correspondence is also clear: this woman Yang was very likely suffering from severe organic liver disease; the gan jue had reached a degree resembling hepatic coma — convulsing all day, skin and bones, unable even to take food. Set such a patient before a modern hospital bed today, and the family’s hearts would sink. Yet the ancients’ approach truly brought her back: regulating qi and unblocking the collaterals to treat the liver, strengthening the spleen and dispelling dampness to protect the stomach, the two formulas alternating — until the whole household rejoiced. The subtlety within is worth savoring slowly.

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