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Xu Shu-Wei Discourses on the Shang Han Lun

by Steven Claven

Xu Shu-Wei 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!

Needling Yang Ming channel to relieve shang han fever, 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 can use 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].

Insomnia: Case number 12

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.

Twitching of tendons and muscles: 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.

Editorial comment: The above two cases 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.

Gui Zhi Condition: Case number 31

In the village home of Zhang the Court Physician, a woman was ill with shang han: fever, aversion to wind, spontaneous perspiration, and floating soft pulse.

I said "She should take Gui Zhi Tang(Cinnamon Twig Decoction)" and they replied "We have it here at home". I directed that she drink three doses. But the illness did not go!

Checking the cooked herbs I found that they had used Rou Gui, and said "Rou Gui and Gui Zhi are not the same!". When I personally gave her Gui Zhi Tang, she was better with one bowl.

Xu's discussion: The rationale behind [Zhang] Zhong-Jing's use of Gui Zhi is in order to utilise Gui Zhi's light mildness, not Rou Gui's thick heaviness. Because Rou Gui is thick and solid, it is used in the treatment of the Five Zang, utilising its heavy settling. Gui Zhi is the tip of the branch, clear and light, and when used to treat shang han, it is its dispersing effect that is being sought.
That is why in this case there was no effect.

Cinnamon Twig Decoction plus Magnolia and Apricot Seed Condition: Case Number Three

In January one year, a soldier in the riverside city of Yi Zheng was captured by Zhang Yu. He was confined, day and night, below decks in a ship where he was bound tightly, unable to stretch.

Several days later he escaped. After a large meal to celebrate, feeling hot, he stripped off his clothes to pick out all the lice, and the following day came down with shang han.

One doctor decided that the large meal was the problem, and so purged him; another thought that the lack of clothing had exposed him to a pathogenic attack, and so sweated him.
After a few days of this sort of miscellaneous treatment, he gradually felt more and more lightheaded and lethargic, and even began wheezing and found it difficult to breathe.
The doctors began to get panicky, but had no idea where they had gone wrong.

I diagnosed him and said: "Purging a Tai Yang condition while the surface has not been released, resulting in mild dyspnoea: Gui Zhi jia Hou Po Xing Ren Tang (Cinnamon Twig Decoction plus Magnolia Bark and Apricot Kernel). This is Zhang Zhong-Jing's protocol."

One of the doctors disputed with me, saying: "I have never used Gui Zhi in my life! Besides, the herb is hot, how could it treat difficult breathing?!"

"This" I said "is a matter of which you know nothing".
One dose settled the dyspnoea, the next brought on a mild sweat all over the body. By that night his body was cool and the pulse had regained its harmony. The doctor exclaimed: "I never imagined that Zhong-Jing's protocols were as miraculous as this!"

I replied "Did you think his protocols were recorded to deceive and confuse later generations? People who study little have scant understanding."

Background to the case:
Gui Zhi jia Hou Po Xing Ren Tang: locus classicus
There are two clauses in the Shang Han Lun which relate to the use of this formula.

Clause 18 (19): Asthma sufferers with simultaneous Tai Yang surface invasion should, during an asthma attack, be given Gui Zhi Tang, adding Hou Po and Xing Zi (ie Xing Ren).
Clause 43 (43): In Tai Yang illness, when purging the patient causes mild difficulty breathing, the reason is that the surface had not yet been freed. The main formula for this is Gui Zhi jia Hou Po Xing Zi Tang.

Comment: "Tai Yang illness" means that they will still have the characteristic surface symptoms of Tai Yang wind invasion: floating pulse, fever, aversion to wind, headache; but they have mistakenly been purged which has led to dyspnoea. (In the Chinese, "asthma", "difficulty breathing" and "dyspnoea" are all the same word: "chuan").

The only difference between the first and the second clauses is that of duration: in the first there has been long term dyspnoea from asthma, now an attack is brought on by the surface invasion. In the second, the incorrect treatment of the Tai Yang wind invasion itself brings on difficulty breathing. Thus there is no difference in treatment.
As to how purging can bring on dyspnoea, Cheng Wu-Ji (1066-1156) explained that there were two cases: 1) if the dyspnoea is severe, this shows that the internal qi is weak, the pathogen has been drawn internally and the qi is on the verge of collapse; and 2) if the dyspnoea is mild, this shows that the internal qi is rebelling upward, the pathogen has not been drawn internally, but still resides on the surface. This is why Gui Zhi Tang can be used to open the surface and expel the pathogen, with Hou Po and Xing Ren added to bring the qi downwards normally.

Main symptoms: fever, spontaneous perspiration, aversion to wind, difficulty breathing, thin white tongue coat, floating soft pulse.

Other possible symptoms: cough with thin white phlegm.
Basic Aetiological Mechanism: Ying and wei qi disharmony, Lung qi ascent and descent disruption.

Here the generalised symptoms of Gui Zhi Tang condition are combined with the localised symptoms of Lung qi disruption. The dyspnoea mainly results from phlegm already present in the Lungs. Phlegm is a yin pathogen with substance, while qi is yang and has no substance. In the Lungs, the yin (phlegm) has a congealing collecting nature, whose quiet substantial inaction is greater than the yang qi's insubstantial dispersing moving nature. The result is a blockage of the normal rise and fall of Lung qi so that breathing is difficult.

Herbal constituents:
Gui Zhi (Cinnamomi Cassiae, Ramulus) 9g
Chi Shao (Paeonia Rubra, Radix) 9g
Zhi Gan Cao (Glycyrrhizae Uralensis, Radix, prepared) 6g
Sheng Jiang (Zingiberis Officinalis Recens, Rhizoma) 9g
Hong Zao (Zizyphi Jujubae, Fructus) 12g
Hou Po (Magnoliae Officianalis, Cortex) 6g
Xing Ren (Pruni Armeniacae, Semen) 9g

Explanation: Most herbal students are well familiar with the ying and wei harmonising effect of Gui Zhi Tang, the pungent warmth of Gui Zhi and Sheng Jiang dispersing the pathogen from the surface; the Bai Shao and Hong Zao replenishing the yin exhausted by the spontaneous perspiration and preventing excessive dispersal; while the Gan Cao's sweetness moderates the dispersing action, giving in effect a "time-release" quality to the formula.

Hou Po and Xing Ren are pungent and warm, but bitter as well, and this bitterness has the effect of draining Lung qi downward, while the pungent warmth breaks up the yin-natured phlegm's substantial congealing within the Lungs. The key is in the descending nature of both these herbs.

Thus it is that this elegant formula manages both the general and the local disharmonies involved in the condition.

Reprinted from the Australian Chinese Medicine Education & Research Council Ltd Newsletter vol.2,no.5 March 1997.For subscription details contact Shen@apelink.net.au

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