3. Twitching of tendons and muscles:

Original case from: Xu Shu-Wei’s Case number 17

A townsperson named Jing made a living in the country village by twisting fibres into rope (“sheng”), and so was known as Jing Sheng Zi — “Roper Jing”.

Her son was almost thirty years old when he became ill, showing a slight sweat, weak pulse, and aversion to wind. The doctor mistakenly gave him Ma Huang Tang to bring on a sweat, and sweat he did — without stop! Fever, chest pain, intense palpitations, unable to sleep at night, and delirium all followed. Soon he did not recognise his mother, and began twitching convulsively, moving and shaking. The doctor then tried heavy sedators and wind extinguishing herbs as treatment.

I saw this and said: “Erroneous forcing of diaphoresis! Zhong-Jing said:

Patients with weak forceless pulse, sweating and aversion to wind cannot be given [Da] Qing Long Tang (Major Blue-Green Dragon Decoction). When they take it the result will be twitching of the tendons and convulsions of the muscles, and coldness of the limbs. “
[Clause 38 (38)]

I continued: “Only Zhen Wu Tang (True Warrior Decoction) can save him. Zhong-Jing says:

Tai Yang illness with sweating that does not stop, and the patient still has fever, palpitations, convulsive twitching that threatens to lift him off the ground: Zhen Wu Tang is the treatment.”
[Clause 82 (84)]

After giving him three doses of the worst was over; as a follow-up Qing Xin Wan (Pill to Clear the Heart) and Zhu Ye Tang (Bamboo Leaf Decoction) was given to relieve any further remaining toxic pathogen. After several days he was cured.

Steve’s comment: The above two cases [see previous Zhu Ling Tang case] are juxtaposed to illustrate Xu’s adroitness in the face of two cases, of exactly similar etiology, with yet differing consequences. Note that while each case suffered insomnia as a result of incorrect diaphoresis, in the second case this was overridden by the severity of the spasming. Each patient, too, varied in constitution and thus treatment necessarily varied.

What impresses me is Xu’s encyclopaedic familiarity with the Shang Han Lun, his appreciation that “These are no idle words!” and his ability to recognise in confusing cases the core symptoms which identify the applicable portion of the classic. Very inspiring! While it is true that we have relatively scant resources for studying the Shang Han Lun in English so far, we should remember that it could not have been easy in Song dynasty China, either.

Translated by Steven Clavey

Tai yin deficiency cold pattern with heat signs
Xu Shu-Wei’s Case

In the beginning, Mr. Cao had cold-damage that lasted for 6-7 days. There was abdominal fullness with vomiting, inability to get food down, a warm body, hot extremities, spontaneous diarrhea, pain in the abdomen, retching, and nausea. The first doctor said there was too much yang, because of the hot extremities. He feared there was an amassment of heat in the stomach leading to vomiting or because there was vomiting and diarrhea this was sudden turmoil disorder. At this point, I (Xu) was asked to give a diagnosis. The pulse was thin and submerged.  One can say that this was a tai yin pattern.

In the disease of the tai yin, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. Therefore, to bring things to a halt, I gave him Regulate the Middle Pill (li zhong wan) the size, as Zhong Jing said, of  “large chicken egg yolks”. The patient took five or six pills during the day and night. This was followed up for several days by Five-Accumulation Powder (wu ji san) and there was resolution.

Translated by: Jason Blalack

Source: (《伤寒九十论•证二十三》)

Commentary: The “hot extremities” has the meaning of  extremities that are not cold and means “extremities that are spontaneously warm”. This specific sign can be understood that this  pattern has not yet reached the shao yin with yang debilitation and yin exuberance, where there is reversal cold of the four extremities. This is therefore only a pattern of tai yin deficiency cold, where Regulate the Middle Pill (li zhong wan) was used to regulate the yang of the middle burner and the patient was healed. Furthermore, the pulse is a classic Regulate the Middle Pill (li zhong wan) pulse, which would make much less sense with a heat amassment pattern.

Original Chinese: 许叔微医案:曹生初病伤寒，六七日，腹满而吐，食不下，身温，手足热，自利，腹中痛，呕，恶心。医者谓之阳多，尚疑其手足热, 恐热蓄于胃中吐呕，或见吐利而为霍乱，请予诊。其脉细而沉。质之日:太阴证也。太阴之为病，腹满而吐，食不下，自利益甚，时腹自痛。予止以理中丸，用仲景云”如鸡子黄大”。昼夜投五六枚。继以五积散，数日愈。

By: Steven Clavey

(Thanks Steve for this case and the one’s that follow. Please check out his journal, The Lantern)

Insomnia: Case number 12, by Xu Shu-Wei

A local notable named Chen, when he first became sick, had fever, floating pulse and spontaneous perspiration. The doctor used Ma Huang Tang to cause sweating, but the fever became severe, Chen could not get to sleep, his head was heavy, there were palpitations and he complained of a restless cooped-up feeling. The mistake was insisting on a strong diaphoretic formula when the condition was [not cold invasion but rather] a wind invasion — zhong feng. Zhong-Jing says:

Tai Yang illness: after using diaphoresis the sweat is heavy, there is parched dryness in the Stomach and insomnia. The patient desires to drink water — give him a little at a time: this will cause the Stomach qi to harmonise and he will be cured. [Clause 71]“

I first used Zhu Ling Tang (Polyporus Decoction) followed by herbs like Dang Gui (Angelica Polymorpha, Radix), Shou Di (Rehmanniae Glutinosae Conquitae, Radix), Mai Men Dong (Ophiopogonis Japonici, Tuber), Bai Shao (Paeoniae Lactiflora, Radix) and Wu Mei (Pruni Mume, Fructus) as a soup to sip.

The sweat stopped and he recovered.

Xu’s Discussion:
The Huang Di Zhen Jing (The Yellow Emperor’s Classic of Needling — ie the Ling Shu) says:

Protective wei qi travels the surface yang during the day, but at night it moves to the internal yin. If it cannot move into the yin internally it will wander ceaselessly outside. This external movement makes the yang full, and this fullness makes the Yang Qiao channel surfeited and unable to transfer into yin. Weakened yin means inability to get to sleep [because the quiet settling of yin is reduced] (Ling Shu Chapter 80).”

In this case the jin and ye fluids are exhausted internally [because of the over-sweating of the treatment], the fluids of the Stomach are parched dry [because the sweating drained the Earth flesh]; the malady concentrated in yang, with no refuge for yin — the symptoms are as we have seen.
Thus Dang Gui and Shou Di are used to tonify blood, while [the sourness of Bai Shao and] Wu Mei are used to contract yin. This stopped the sweating and the patient naturally recovered.

Needling Yang Ming channel to relieve shang han fever, Xu Shu-Wei‘s Case (number 55)

One year in the month of May, a Mr. Li was ill with shang han (injury by cold), having fever, headache, no sweat and generalised aching all over the body. The pulse was floating, big and tight. I gave him Ma Huang Tang, but after several doses there still was no sweating; again we tried Zhang Miao’s roasting steaming method, and this did not work either. I then ordered acupuncture on Yang Ming, and after a short while perspiration appeared, misting the whole body for a period. By evening he was cool and the illness receded.

Xu’s Discussion:
Chapter 32 of the Su Wen, entitled “Ci Re Lun/Treatise on Needling Heat”, says:

Febrile illness with pain first in the arms, needle Yang Ming and sweating will relieve it.”

It also says:

Needle Yang Ming, letting a drop of blood the size of a large bean, immediate relief”

The Yang Ming point to be needled is that on the inner side of the finger, just under the nail, which is the point from which the Yang Ming channel originates (ie Shang Yang, L.I. 1). Needle to a depth of one fen, and leave for one breath.

In most cases of shang han febrile disease in which there is difficulty raising a sweat, nothing is more marvellous than needles. [Zhang] Zhong-Jing says: “Any treatment of wen/febrile disease cause the 59 points”. The Su Wen says: “In severe cases, employ the 59 needling”. What this means is explained in the annotations [to the Classics].

Xu Shu-Wei

(Thanks Steve for this introduction and the case studies that follow. Please visit his Chinese medicine journal, The Lantern.)

Xu Shu-Wei (许叔微) was a well-known physician who lived during the Southern Song Dynasty (1075 – c. 1156). Having attained a certain level in the imperial examinations, he was known as Xu Xue-Shi — `Xu the Scholar’. He was the author of numerous works in the Shang Han Lun tradition, among which are the famous Lei Zheng Pu Ji Ben Shi Fang (Classified Formulas of Universal Benefit from My Practice), the Zhu Jie Shang Han Bai Zheng Ge (Annotated Odes of One Hundred Shang Han Conditions) and the Shang Han Jiu Shi Lun (Ninety Discourses on the Shang Han Lun). The following selections are from the latter.

This book was quite rare until its recent republication, for reasons which an editor to the comprehensive collection of Chinese books during the Qing dynasty, the Si Ku Quan Shu, describes:

[Xu] Shu-Wei’s books are written in simple yet elegant prose which does nothing to endear itself to the vulgar. Thus ever since the Ming dynasty they have not been widely disseminated. Extant texts are few, and so our Collectors have none to peruse.

This essay supplies a bit of background material for the final case discourse, in order to provide orientation in the Shang Han Lun tradition and illustrate the level of understanding this entailed. Not that Xu himself needs much help: he is unusually clear in his explanations and quite scathing in his description of those doctors who, after initially making a mess of their patients, still dared to dispute his judgement when he came to the rescue!

Case 1 – Shang Han Fever – Needling the yang ming: Case #55
Case 2 – Zhu Ling Tang- Taiyang- Insomnia: Case #12
Case 3 – Zhen wu tang – Twitching of tendons and muscles: Case #17
Case 4 – Gui Zhi Condition: Case #31 (Coming Soon)

(Reprinted  from the Australian Chinese Medicine Education & Research Council Ltd Newsletter vol.2,no.5 March 1997.)