Belly Swollen Like a Drum? Doctor Zhu Danxi’s Treatment of Ascites: One Patient Died Clinging to a Fixed Formula, Another Recovered in Six Months

Opening: in the eyes of the ancients, this was one of the four incurable diseases

Today we continue with the case stories of Doctor Zhu Danxi (朱丹溪). A physician of the Yuan dynasty and one of the “Four Great Masters” of Jin-Yuan medicine, he laid out the causes and courses of many serious illnesses with remarkable clarity in his book Ge Zhi Yu Lun (《格致余论》, Extra Treatises Based on Investigation and Extension of Knowledge). The disease in today’s story once made people pale at the mere mention of it — drum distension (gu zhang, 鼓胀).

💬 Note from Doctor Luo: The ancients listed four great severe illnesses — “wind, consumption, drum, and diaphragm” (feng, lao, gu, ge) — four terminal diseases, and drum distension stood right among them. What does “drum” mean? The belly swells up like a drum. In ancient times this disease was seen as extremely difficult to treat, almost a death sentence.

What does it look like? A “spider-belly”

What are the features of drum distension? The illness develops slowly and chronically: the belly swells up day by day, tight as a drum; the skin is stretched taut, and its color turns a sallow, grayish yellow. The most frightening sign is the appearance of spider veins on the abdominal wall — blood vessels showing faintly through the skin like a spider’s web.

💬 Note from Doctor Luo: In the later stages, the belly is often hugely distended while the arms and legs grow extremely thin — a big belly with spindly limbs, like a spider. That’s why the ancients called it “spider swelling” (zhi zhu zhang). The condition closely resembles what we now call cirrhotic ascites or kidney-disease ascites. The ancients also classified it by cause: when qi dominates it was called qi-drum, when water dominates, water-drum (edema); when spider veins were prominent, blood-drum. Different causes, different treatments.

First, a counter-example: a friend who understood medicine — and “treated” himself to death

Doctor Zhu Danxi had a friend named Yu Renshu (俞仁叔), a ru sheng — a Confucian scholar who also knew medicine. In those days many educated men dabbled in medicine, and Yu was one of them. But this man suffered one family disaster after another: death after death, calamity after calamity in his household. His mood, naturally, was terrible.

💬 Note from Doctor Luo: Remember this: bad emotions — constrained liver qi, liver qi stagnation — are a major cause of drum distension. At fifty, Yu Renshu came down with the disease himself, and he made his own Yu Yu Liang Wan (禹余粮丸, Limonite Pill) to treat it. The formula is recorded in the Dan Xi Xin Fa (《丹溪心法》, Danxi’s Experiential Methods), and it existed in several versions through history. It contains many warming herbs, including fu zi (aconite).

When Doctor Zhu Danxi took his pulse, he found it wiry, choppy, and rapid. Wiry — constrained liver qi, and also retained fluid. Choppy — stasis and obstruction, blood stasis inside. Rapid — the pulse beating fast, which indicates heat. Doctor Zhu Danxi concluded that his friend harbored stagnant heat within. He advised him: “You’ve just finished making this medicine, haven’t you? Yu yu liang (limonite) is a mineral that must be roasted with fire. The fire pathogen from the roasting is still in it — the fire-qi remains inside, and on top of that the formula is full of warming herbs. You should modify it. Do not cling to a fixed formula — don’t die holding onto this single prescription.”

💬 Note from Doctor Luo: When the ancients made pills and medicines, they were very particular about “removing the fire qi.” My maternal grandfather was skilled at making medicated plasters, and every finished plaster had to be set into a vessel and slowly cooled on the ground until its fire qi was completely gone before use — otherwise the heat left inside would raise blisters when applied to an injury. For mineral medicines roasted by fire, the fire qi absolutely must be eliminated. But how did Yu Renshu answer? He smiled and said: “People of today are not as good as the ancients — how could one alter an ancient formula?” He insisted that modern people could never match the ancients, and once a formula was fixed, it could not be touched.

And the result? He clung to Yu Yu Liang Wan, taking it for a whole month — until blood appeared from his mouth and nose, and in the end he died standing on his own bones (gu li er si): wasted away to a skeleton, gone.

💬 Note from Doctor Luo: This is a failed case — but not one Doctor Zhu Danxi treated. He pointed out the error on the spot; the pity is that his friend would not listen. Was the formula itself bad? No — Doctor Zhu Danxi himself accepted Yu Yu Liang Wan as a valid prescription. But it was used on the wrong pattern. A good medicine is only good when it matches the syndrome; used in the wrong situation, even an excellent formula can kill. This case also shows that in those days, people’s understanding of drum distension was still shallow.

How did people treat drum distension back then?

There was a very important approach to drum distension in ancient times — drain it outward: isn’t there water in your belly? Then promote urination and purge the bowels, driving it down with fierce, drastic herbs.

💬 Note from Doctor Luo: This way, the belly did go down for a while — it slowly deflated. But the water soon came back, and the belly swelled again. Further treatment no longer worked; the patient grew weaker and weaker, and finally died. Some people even stuck needles into the belly to let the water out — some water came out, the belly flattened briefly, then it relapsed, and further needling was useless. These wrong methods were once very popular. It was only because masters like Doctor Zhu Danxi set the reasoning straight that the proper approach gradually took hold.

Now a living example: Brother Yang, fifty years old, a daily drinker

Among Doctor Zhu Danxi’s records is Brother Yang, nearly fifty years old. The doctor even wrote down his personality — this man loved alcohol and drank every day.

💬 Note from Doctor Luo: Many cases of drum distension are linked to drinking. Why does cirrhosis ascites happen today? Years of drinking damage the liver, and eventually the fluid accumulates. Yu Renshu’s case was driven by bad emotions; Brother Yang’s by alcohol — but there are also schistosomiasis, severe kidney qi deficiency, and severe spleen qi deficiency, all of which can produce this disease.

Brother Yang, past fifty, drinking daily, happened to catch malaria that dragged on for half a year, badly wounding his upright qi — and then came the drum distension. He himself felt certain he would die. With no other recourse, he invited Doctor Zhu Danxi to treat him.

Doctor Zhu Danxi took the pulse — then delivered a great lecture

The pulse was wiry and choppy, and large when pressed deeply — wiry meaning stagnation, choppy meaning obstruction, and large on deep pressure showing that evil qi (damp-heat) was lodged inside. What’s more, the malaria had not resolved; the malaria qi was still present. Then he looked at the man: hands and feet thin, belly huge — the shape of a spider.

💬 Note from Doctor Luo: Arms and legs that thin mean severe malnutrition — spleen qi greatly depleted. The spleen governs the four limbs; when the limbs are thin, the spleen qi is insufficient. The big belly means phlegm turbidity and blood stasis accumulating inside. When spleen qi is deficient, it cannot send the clear upward and the turbid downward; water-damp and stagnant blood all jam up in the belly, and transformation and transport come to a halt.

Then Doctor Zhu Danxi delivered a discourse that later generations would quote again and again. He said: the heart and lungs belong to yang and reside above; the liver and kidneys belong to yin and reside below; the spleen sits in the middle, belonging to yin and to earth. After food and drink enter the stomach, the spleen is what distributes nourishment to the whole body — so the function of the spleen and stomach is absolutely crucial. Drum distension, to a very large degree, is connected to injury of the spleen. How does the spleen get injured? Through the seven emotions wounding internally (bad moods, tormenting yourself all day), the six excesses invading externally (when upright qi is weak, external pathogens slip in), irregular diet and drink (either alcohol or careless eating, which wounds spleen yang), and exhaustion through excessive sexual activity (depleting kidney essence) — in short, the yin of the spleen-earth is injured.

💬 Note from Doctor Luo: When the spleen-earth is wounded, its job of distributing nourishment breaks down — it can neither raise the clear nor lower the turbid. In classical terms, heaven and earth fail to meet, and the hexagram becomes Pi (否, “Standstill”) — the qi of the heart and lungs above will not descend, the kidney water below cannot rise, and the upper and lower body lose communication. So the clear and the turbid mix together, and the passages become blocked: filthy dampness, stagnant blood, and phlegm-damp all jam up inside. Qi transforms the turbid blood-stasis into heat, damp-heat binds together, and drum distension is formed — this is the drum distension described in the classics, in the Huang Di Nei Jing (《黄帝内经》). When you knock on such a belly it sounds “bong-bong,” hollow inside, and it is extraordinarily stubborn and hard to cure.

How to treat it? Doctor Zhu Danxi laid down the great principles: tonifying the spleen is the most important thing; at the same time nourish the lung metal in order to control the wood — build up the lung channel so it can rein in the liver wood and stop it from bullying the spleen and stomach; nourishing the lung is in effect nourishing the kidney water, and one also adds kidney-tonifying herbs to control fire, keeping the lung metal pure and clear. In daily life, one should also: eat less salt (salt makes you drink more water, worsening the condition), and cut off delusions in order to protect the mother qi.

💬 Note from Doctor Luo: “Cutting off delusions” is the key secret to treating this disease. If you want to get well, first stop the wild thoughts and desires. Still hoping for promotion, a hundred million in the bank, or the attentions of beauty? Cut all those delusions off — they have very little to do with you. Only by cutting off delusions can this disease be regulated back to health. Whenever later generations discuss drum distension, they invariably quote this discourse of Doctor Zhu Danxi; its status is extremely high.

The prescription: Eight Treasures Decoction minus prepared rehmannia, plus three small assistants

For Brother Yang, Doctor Zhu Danxi wrote: ren shen (ginseng) and bai zhu (atractylodes) as the sovereign herbs (in large doses), with dang gui (angelica), chuan xiong (ligusticum), and shao yao (peony) as the ministers to regulate the blood.

💬 Note from Doctor Luo: In all the cases of Doctor Zhu Danxi I have told, he basically opens with ren shen and bai zhu as the lead. Some people claim Zhu Danxi only nourished yin, cleared heat, and damaged yang — those people have clearly never actually read his case records; they are repeating nonsense they heard somewhere. Here he opens with ren shen and bai zhu as sovereign — he clearly valued supplementing qi and yang the most. Notice there is no shu di huang in the formula — the prepared rehmannia of the Four Substances was removed. Why? For fear of cloying stagnation. The spleen and stomach are already severely deficient and dampness is heavy; at this point prepared rehmannia must be used with great caution. So he used only dang gui to nourish the blood, chuan xiong to harmonize blood and move qi, and shao yao to constrain the liver and nourish the blood. Ren shen, bai zhu, fu ling, plus dang gui, chuan xiong, shao yao — this is Ba Zhen Tang (Eight Treasures Decoction) minus shu di huang — supplementing both qi and blood together.

Then he added small amounts of huang lian (coptis), chen pi (aged tangerine peel), fu ling (poria), and hou po (magnolia bark) as assistants, plus a little gan cao (licorice). What does huang lian do? It clears damp-heat — there is still evil qi inside; the malaria is not resolved, damp-heat and stagnant blood are blocking things up, so a little huang lian clears the damp-heat. Chen pi moves qi — when you supplement, the qi must not congest inside, it must circulate; fu ling both helps ren shen and bai zhu supplement the spleen and drains water-damp; hou po moves qi and drains water, breaking up the dampness accumulated in the middle and lower burners; raw gan cao harmonizes all the herbs.

💬 Note from Doctor Luo: This prescribing style follows the same road as Doctor Li Dongyuan: a large pile of qi-supplementing, spleen-supplementing herbs, with a tiny bit of huang lian or huang bai at the back to clear damp-heat. To use a modern analogy — think of the gut microbiome and it becomes immediately clear: the ren shen, bai zhu, fu ling, and huai shan yao in front are food for the beneficial bacteria; and the harmful bacteria? You use a little huang lian to clean them out. Chinese medicine calls this “clearing damp-heat, improving the intestinal environment”; modern science calls it “improving the gut microbiome.” The two absolutely can be bridged — research in this direction will surely bear fruit.

The medicine was made into a concentrated decoction drink, taken three times a day. Doctor Zhu Danxi also gave strict instructions: observe the prohibitions faithfully — don’t eat very salty food, don’t eat rich, fatty, sweet delicacies; cut off delusions — stop scheming about making friends with high officials and rich merchants, stop drinking, stop chasing after beautiful women; stay home quietly, practice standing meditation (zhan zhuang), practice tai chi, and take regular walks to settle the spirit.

Sweating in one month, cured in six

Brother Yang listened — and observed the prohibitions strictly. After one month, the malaria resolved with sweating — just as in the earlier cases, the sweat came, the qi and blood began to circulate, and the illness was over.

💬 Note from Doctor Luo: As soon as Doctor Zhu Danxi explained, he said, “I’ll be good, I will strictly observe everything” — that is an obedient patient. Some people are told to stop drinking and drink anyway; nobody can save those.

Then he kept taking the medicine steadily for another six months — and the urine flowed freely, and the drum distension was cured. The urine output increased, and the water-damp in the belly left through the urine. There were modifications along the way, but the general intent was always simply to supplement qi and move dampness.

💬 Note from Doctor Luo: Look at Doctor Zhu Danxi’s thinking on drum distension: he knows there is blood stasis and phlegm-damp inside, and it presents as an acute, severe, excess-type disease — but in reality many of these patients are deficient. The spleen and kidneys are already badly depleted, so supporting the upright qi comes first. This principle was inherited and carried forward by later generations.

The story travels to the Ming dynasty: Gong Tingxian treats the Prince of Lu’s consort

This line of thinking was passed down unbroken, and in the Ming dynasty it produced a famous example — the Jiangxi physician Gong Tingxian, who later became an imperial physician.

💬 Note from Doctor Luo: The consort of the Prince of Lu came down with the very same disease — a great deal of anger, plus overindulgence in rich food and drink, until she lay in bed unable to move: belly enormously distended, arms and legs paper-thin, like a spider. She could barely swallow medicine, could not sleep, could not eat — the woman was at death’s door. Every physician failed. How did Gong Tingxian treat her? Bu Zhong Yi Qi Tang (Tonify the Middle and Augment Qi Decoction) combined with Liu Wei Di Huang — supplementing both yin and yang — plus food-based spleen tonics: shan yao (Chinese yam) and lian zi (lotus seeds) made into pills (Rui Lian Wan, the Auspicious Lotus Pill) for her to take, slowly supporting the upright qi. As her upright qi increased, the body gradually recovered. The Prince of Lu was so impressed that he presented Gong with an inscribed plaque — “Champion of the Medical Forest” (yi lin zhuang yuan) — declaring him the number one physician under heaven.

💬 Note from Doctor Luo: Would you dare to drain water in a case like that? The woman was barely alive; draining would have finished her off. Gong Tingxian insisted on supporting the upright qi — and cured her. This line of thought has been handed down ever since; even today, when Chinese medicine treats ascites, it still has real strategies. The ancient sages left us a great deal of wisdom.

Doctor Luo’s two reminders

First, if it really is drum distension, treat it early — without fail. Take cirrhosis ascites: the moment the first signs appear — the belly starts swelling, the navel begins to flatten, spider veins begin to show — that is the time to see a Chinese medicine practitioner early; the results are much better.

💬 Note from Doctor Luo: Too often people come to me only at the rescue stage: “My father has cirrhosis ascites, he’s in emergency right now, belly enormous — can you write a prescription?” They only look for Chinese medicine when the patient is already critical, and then the treatment demands far more effort and is much harder. Try to start regulating as soon as the first signs appear: support the upright qi steadily, occasionally add a little blood-moving herb, a little damp-heat-clearing herb — with supporting the upright as the main thread — and slowly dissolve it away.

Second, watch out for “ascites-like syndrome” (lei gu zhang) — a term I coined. Such people may not have true cirrhosis or kidney-disease ascites with a giant belly and bulging blue veins, but they do have similar symptoms: a bloated belly, a big belly. This is not the life-threatening emergency of true drum distension, but it is the beginning of the body’s decline.

💬 Note from Doctor Luo: What causes it? Chronic illness, or excessive self-damage — too much indulgence, or extremely bad emotions. The signature is obvious: the bloating is worst in the afternoon — usually starting around three or four or five in the afternoon and growing worse, like pregnancy; over the course of a year it improves in summer, begins in autumn, and is severe by winter; within a single day it swells in the afternoon and evening, then seems to deflate after a night’s sleep; and eating even a little food makes it immediately much worse — the person can hardly eat anything. This is the face of spleen-kidney decline; if it worsens and liver disease is added, it can turn into cirrhosis ascites.

How to regulate it? Follow Doctor Zhu Danxi’s approach: first, regulate the emotions; second, persist in supplementing the spleen and draining water — supplement qi, supplement the spleen, add a little damp-heat-clearing, toxin-removing herb, and slowly regulate the depletion. Don’t be impatient; this disease will not resolve overnight — it takes two to three months of medicine before results show. Meanwhile, stick to whole grains, shan yao, and lian zi as dietary support. If you manage to turn it around, it is like being reborn; if not, left to develop, the heart and kidneys will eventually run into serious trouble.

💬 Note from Doctor Luo: If you want to use patent medicines, you can take Bu Zhong Yi Qi Wan in the morning and Gui Pi Wan (Returning the Spleen Pill) in the evening, steadily, to build the spleen qi back up; of course, decocted medicine is better. Remember: that state of “I don’t know what disease it is, just a bloated belly that swells badly in the afternoon” is a signal of internal disharmony and visceral depletion — it must be taken seriously.

What to take away: a belly swollen like a drum was one of the four “terminal diseases” of the ancients — and Doctor Zhu Danxi’s answer was not to drain the water, but to support the spleen first. One patient died because he refused to adapt a fixed formula; another recovered in six months because he supplemented qi, moved dampness, and cut off his delusions. If your belly swells worse in the afternoon, improves in summer and worsens by winter, and balloons the moment you eat — don’t wait for the emergency room. Regulate your emotions, build up the spleen, and treat the problem while it is still small.

Compiled from Doctor Luo Dalun’s explanation of Doctor Zhu Danxi’s case records; the case comes from On Drum Distension (《格致余论·鼓胀论》).