Bloody Stool and a Black, Swollen Belly? Doctor Zhu Danxi’s Blood-Nourishing Treatment of Ascites in a Woman
What patients search for: blood in the stool / blood passed with bowel movements / bloated belly / belly swollen large / belly turning black / female abdominal bloating / bloating that is worst in the afternoon / bloating right after eating
Corresponding medical terms: drum distension · bloody stool · spleen deficiency with retained water · blood deficiency with blood stasis · internal damp-heat · ascites-like syndrome
Opening: let’s talk about the “ascites-like syndrome” — for many people, this is their sub-health
Yesterday we told the story of how Doctor Zhu Danxi (朱丹溪) treated drum distension (gu zhang, 鼓胀). Today we continue. In the past, this disease was common in the countryside — the big, drum-like belly caused by schistosomiasis was seen all the time. But today, true drum distension has become rare. However, there is a condition I call the “ascites-like syndrome” (lei gu zhang) — no such name exists in the medical canon; I coined it myself. It means: the spleen and kidneys are deficient, phlegm-damp accumulates in the body, water-damp congeals into phlegm, and on top of that there is blood stasis — so the belly swells up slightly.
💬 Note from Doctor Luo: People with the ascites-like syndrome do not necessarily have real ascites fluid — but their bellies are bloated: it is worse as the afternoon wears on, worse in autumn and winter, worse after eating something cold; the belly bloats the moment they eat; their appetite is tiny; it also bloats when they catch a chill, and bloats when they get angry. A great many people in a sub-healthy state have exactly this problem. They go to the hospital, and nothing is found. So the ancient approach to regulating drum distension can be borrowed wholesale for them.
Who was the patient? A heavy-drinking woman past forty
Today’s case comes from Doctor Zhu Danxi’s records: Madam Chen, a woman past forty. And this woman had a notable habit — she loved alcohol.
💬 Note from Doctor Luo: “Loving alcohol” here doesn’t mean the little medicinal sip a health-conscious person enjoys. It means she genuinely liked to drink — drinking heartily, drinking joyfully. Drink like that for long enough, and the body will run into trouble sooner or later.
What were her symptoms? First, blood appeared in her stool from time to time (da bian shi jian xue). What does blood in the stool usually mean? Occasionally it comes from cold, but in most cases there is heat — heat forcing the blood to run wild; it can also be spleen deficiency failing to command the blood. For Madam Chen, heat was quite likely. Second, in the spring she developed distension — her belly began to swell.
How bad was it? A belly black and swollen — the shape of a ghost
What did her distended belly look like? The belly was dark in color and hugely distended (du zhang se hei er fu da) — the skin had turned black, and the belly was swollen very large.
💬 Note from Doctor Luo: Darkened skin means heavy dampness and stasis underneath. And add to that the description “shaped like a ghost” — her arms and legs were extremely thin while her belly was enormous, like the ghosts in old paintings. At a glance: face dark, belly huge — like a ghost.
Then Doctor Zhu Danxi took her pulse: rapid and choppy (shu er se). Rapid — the pulse beating fast, which indicates heat inside. Choppy — stasis and obstruction, the qi and blood not circulating smoothly. And weak when pressed deeply — qi and blood insufficient. Heat, stasis, and at the same time qi-blood deficiency — that was Madam Chen’s foundation.
Doctor Zhu Danxi’s thinking: for a woman, nourish the blood first
How to treat it? Doctor Zhu Danxi wrote: Si Wu Tang (Four Substances Decoction) plus huang lian (coptis), huang qin (scutellaria), mu tong (akebia stem), bai zhu (atractylodes) and chen pi (aged tangerine peel), then supplementing raw gan cao (licorice), made into a decoction.
💬 Note from Doctor Luo: Si Wu Tang — dang gui (angelica), chuan xiong (ligusticum), shao yao (peony), shu di huang (prepared rehmannia) — is the classic formula for nourishing the blood, and here it forms the base. Why lead with Si Wu Tang today? There is a subtlety here: for many diseases, men and women suffer the same condition, yet the emphasis in treatment differs — for men we think more of qi deficiency, for women more of blood deficiency. There is an old saying among the people: men are raised by qi, women are raised by blood. That saying carries a grain of truth — it reflects a rough probability: women menstruate, so their blood genuinely tends to run short, and once the blood is deficient, all kinds of problems appear.
Compare this with yesterday’s case: Brother Yang, nearly fifty, was treated by Doctor Zhu Danxi with ren shen (ginseng) and bai zhu (atractylodes) as the sovereign herbs — supplementing qi as the main approach, nourishing blood as the auxiliary, plus damp-heat-clearing and qi-moving herbs. Today’s Madam Chen, in contrast, is treated with nourishing the blood as the main approach and supplementing the spleen as the auxiliary, plus herbs that drain damp-heat and move qi. Put the two cases side by side, and the difference lies precisely in the emphasis on “qi” versus “blood.”
💬 Note from Doctor Luo: Doctor Zhu Danxi attached enormous importance to supporting the upright qi in his prescriptions. He knew the root of this disease is upright qi insufficiency — it may look like an excess pattern, like blood stasis and water-damp, but the root is that the upright qi is not enough. This woman’s blood deficiency was obvious, so he opened with Si Wu Tang to nourish the blood; then he added bai zhu to supplement the spleen and qi, because there was certainly spleen deficiency as well — when the spleen is weak, water-damp settles and stagnates inside.
Breaking down the prescription: spleen-supplementing, qi-moving, water-draining, heat-clearing — each in its place
How do we read this formula? Bai zhu supplements the spleen and qi; matched with hou po (magnolia bark) to move qi and drain water; mu tong drains urine outward, carrying heat and dampness out through the urine; chen pi moves qi — when you supplement qi, supplement the spleen, and nourish the blood, can the medicinal force actually circulate? Water-damp congealing is also a sign that the qi mechanism is blocked, so chen pi on one hand helps transform the water-damp, and on the other helps the supplemented medicine be absorbed and delivered throughout the body.
💬 Note from Doctor Luo: Then come huang lian and huang qin to clear damp-heat. Notice: Doctor Zhu Danxi did not record the doses, but they must have been very small — when clearing damp-heat, touch it lightly and stop there. As I explained before, this connects to the gut microbiome: the spleen-supplementing, upright-qi-supporting herbs are food for the beneficial bacteria, while huang lian and huang qin clean out the harmful bacteria. That is why so many famous spleen-supplementing formulas from the ancients include a little huang lian or huang qin inside the tonics — Doctor Li Dongyuan was skilled at this, and so was Doctor Zhu Danxi.
Slow work makes fine results: sip it daily, and be well in nearly a year
This formula, Doctor Zhu Danxi had Madam Chen take for a year — drinking it daily, slowly — and by the time nearly a year had passed, she was completely cured.
💬 Note from Doctor Luo: Reading the two cases together: yesterday the emphasis was supplementing qi, today it is nourishing the blood; the rest of the medicines were more or less the same, adjusted only slightly. And both patients recovered. Doctor Zhu Danxi never fought hasty battles when regulating this kind of chronic depletion.
What is the “Kingly Way”? The heart-method Doctor Zhu Danxi learned from his teacher
In his day, a saying was current: “qi must not be supplemented” (qi wu bu fa) — as if qi could not casually be built up. Why the fear? The fear that the more you supplement, the more bloated you get. Doctor Zhu Danxi addressed this in detail, and what he taught was really the principle of supporting the upright:
💬 Note from Doctor Luo: Evil qi — water-damp, phlegm-damp, blood stasis — is blocked up inside, clogging the movement of the channels. How do you open it up? You can transform phlegm and drain dampness, you can break up blood stasis. But if your upright qi is insufficient and the body is weak, no medicine works well. So supporting the upright is the crucial move: supplement qi where qi needs supplementing, nourish blood where blood needs nourishing; once the qi and blood are sufficient, the channels and vessels flow freely again, and the evil qi will gradually be pushed out on its own. That is Doctor Zhu Danxi’s great strategy for regulating this class of disease.
Doctor Zhu Danxi said: regulate slowly. It is slower than the other approach — others expel the evil: water in the belly? Force the urine, let it gush out. Constipated? Purge, let it pour away. Fast, yes — but can the body take it? The patient is already weak; one good purge, and something breaks. Slow regulation, by contrast, is called the Kingly Way (wang dao zhi fa): I raise the upright qi, and coordinate it with a small measure of evil-expelling medicine.
💬 Note from Doctor Luo: The relationship between supporting the upright and expelling evil — Doctor Zhu Danxi explained it with exceptional clarity. It is one of his greatest scholarly contributions. This heart-method came from his teacher Luo Zhiti (罗知悌), who placed extraordinary weight on supporting the upright: support it until the upright qi is sufficient, and then one good purge settles everything. Doctor Zhu Danxi inherited this thinking and always valued the patient’s upright qi when treating disease. This is the Kingly Way of treatment — everyone should study it.
What we learn: Doctor Zhu Danxi’s approach to regulating women’s bodies
This case record is very short — we finish it in a moment. So what do we learn? — Doctor Zhu Danxi’s approach to regulating women’s bodies.
💬 Note from Doctor Luo: Doctor Zhu Danxi’s case records contain a striking number of female patients — quite distinctive for his time. He sympathized deeply with women: in discussing mother-in-law and daughter-in-law relations, he usually sided with the daughter-in-law, and he was strongly opposed to mothers-in-law berating their daughters-in-law. Many later gynecological approaches trace their roots to Doctor Zhu Danxi.
The way this case begins is itself distinctive: with drum distension and spleen deficiency, the conventional move is to supplement the spleen. But Doctor Zhu Danxi saw the special situation of the female patient — once the blood runs short, every other problem becomes more severe. So he led with nourishing the blood (Si Wu Tang), made blood-nourishing the main approach, added a little spleen-supplementing, and then the rest of the herbs.
💬 Note from Doctor Luo: When regulating a woman’s body, you must elevate “nourishing the blood” to a position of high importance. Even though this disease looks like an excess pattern — water to drain, blood stasis to break up — remember: it is always upright qi insufficiency that allows blood stasis and water-damp to stagnate in the first place. And for women, you must always ask whether the blood has run short. That is the point to take away today.
Bonus: drum distension is a chronic disease — not the same as “my belly bloated because I ate something cold”
Doctor Zhu Danxi said of drum distension: “this disease arises over three to five years, or ten-odd years; its roots are already deep and firm” (ci bing zhi qi, huo san wu nian, huo shi yu nian, gen shen yi shi gu yi) — it develops extremely slowly, from long-term bad emotions, drinking, or diseases of the kidneys and liver; the root goes very deep. It cannot be cured in two doses of medicine. It must be regulated slowly, gradually changing the body’s overall pattern.
💬 Note from Doctor Luo: The drum distension Doctor Zhu Danxi describes is a very serious depletion disease, closely comparable to today’s ascites (“floating water”). Both of his case patients were heavy drinkers — their ascites was most likely caused by liver damage. So each of them needed a long course of regulation before truly getting well. But this kind of recovery is excellent for the patient: it is not merely that the belly stops swelling — the whole body becomes healthy again.
And what of the “ascites-like syndrome”? — abdominal bloating caused by spleen-kidney deficiency, liver qi stagnation, and the congealing of water-damp and blood stasis. It too is acquired over a long time, and the person usually has other underlying problems — kidney qi deficiency, or an injured spleen. Regulate it slowly, and don’t be impatient.
💬 Note from Doctor Luo: But make the distinction: someone says, “These past two days, my belly bloats when I eat — it swells up right away.” That is acute abdominal bloating, a different thing from drum distension: qi stagnation from anger, a sudden chill, drinking cold water, eating cold food — the belly swells. That is an acute condition. Acute conditions can be handled with purging or qi-moving methods — for example, Mu Xiang Shun Qi Wan (Saussurea Qi-Regulating Pill) to open the qi, or Fu Zi Li Zhong Wan (Aconite Middle-Regulating Pill) to invigorate yang and drain the cold-water down. These regulate it very well. But also ask yourself: why did you suddenly get blocked up like that? It shows your daily upright qi is not especially strong either — so tending the upright qi in daily life is still needed.
What to take away: when a woman’s belly swells and darkens, and blood appears in the stool, Doctor Zhu Danxi did not rush to drain the water or attack the stasis — he nourished the blood first with Si Wu Tang, added a little spleen support, a little damp-heat clearing, and let her sip it daily for nearly a year. Blood nourished, spleen built, qi and blood flowing — the evil qi was pushed out on its own. That is the Kingly Way: for men think of qi, for women think of blood, and always weigh the upright qi before anything else.
Compiled from Doctor Luo Dalun’s explanation of Doctor Zhu Danxi’s case records; the case comes from On Drum Distension in Ge Zhi Yu Lun (《格致余论·鼓胀论》).