The Three Patterns and Treatments of Convulsion Disease (Jing Bing) in the Jin Gui Yao Lue

"Jing bing" (convulsion disease) is a specific TCM term. Its main symptoms are rigidity of the neck and back, convulsion of the limbs, even lockjaw and opisthotonus. Clinically, its common syndrome feature is tension and contracture of the muscles and tendons; it may present as sudden lockjaw, limb convulsion and opisthotonus, or may present only as spasm and rigidity of certain zang-fu organs or meridians. These symptoms resemble those of tetanus or high-febrile convulsions induced by infectious diseases in modern medicine, but TCM convulsion disease covers a broader scope.

The Jin Gui Yao Lue (Essential Prescriptions from the Golden Cabinet) is the earliest TCM classic discussing the patterns and treatments of convulsion disease. In the chapter "On the Pulse, Syndromes and Treatment of Jing, Shi and Ye Diseases, Second," Zhang Zhongjing discusses in detail the symptoms, patterns and treatments of convulsion disease.

The Jin Gui Yao Lue describes the features of convulsion disease as follows: "In taiyang disease, if there is fever without sweating and aversion to cold is present, it is called rigid convulsion (gang jing). In taiyang disease, if there is fever with sweating and no aversion to cold, it is called soft convulsion (rou jing). In taiyang disease, if there is fever and a deep fine pulse, it is called convulsion and is difficult to treat. In taiyang disease, excessive sweating leads to convulsion. In wind disease, purging causes convulsion; further promotion of sweating will surely cause tension. In patients with sores, although the body aches, sweating must not be promoted, for sweating leads to convulsion. The patient has body heat, cold feet, rigid neck and nape, aversion to cold, occasional heat of the head, red face, red eyes, isolated shaking of the head, sudden lockjaw and backward-extended back; this is convulsion disease. If sweating is promoted, cold-dampness combines, the exterior becomes more deficient, and aversion to cold worsens. After sweating, the pulse is like a snake moving, and the abdomen suddenly becomes distended; this indicates the disease is about to resolve. If the pulse remains unchanged and instead becomes deep and wiry, it is convulsion. The pulse of convulsion, on pressure, is tight like a string, straight up and down. If there are moxibustion sores in convulsion disease, it is difficult to treat."

Here several types of convulsion disease are distinguished: one is rigid convulsion without sweating but with aversion to cold; one is soft convulsion with sweating but without aversion to cold; and one is convulsion with fever and a deep fine pulse. It is also pointed out that convulsion disease is mostly caused by erroneous sweating or erroneous purging. The clinical symptoms of convulsion are: "body heat, cold feet, rigid neck and nape, aversion to cold, occasional heat of the head, red face, red eyes, isolated shaking of the head, sudden lockjaw and backward-extended back." It is also noted that patients with sores (those with a history of trauma or ulcer disease), or those with a history of moxibustion leaving moxa sores, have a poor prognosis. If a patient with sores has fever and pain, sweating must not be promoted, because sweating readily leads to convulsion disease. This shows that Zhang Zhongjing already recognized that the sweating method could worsen tetanus.

Tetanus is an acute infectious toxic disease caused by Clostridium tetani infection; if improperly treated, its mortality can reach 100%. Zhang Zhongjing already recognized that tetanus patients respond poorly to TCM treatment, so when we encounter tetanus patients clinically, we should not attempt TCM treatment; we must have the patient urgently admitted and treated with comprehensive methods, without delay.

However, if it is not tetanus, most convulsion diseases can still be treated with TCM, and basically the sweating method or purging method should be adopted. But the sweating method must be used with particular caution in such patients, because in some patients the exterior-deficiency symptoms worsen after sweating, with greater aversion to cold. If after sweating the patient's pulse moves like a snake and the abdomen becomes distended, it indicates the condition is improving and about to resolve or self-heal. The pulse in convulsion disease is mostly wiry; if the pulse remains wiry after sweating, or becomes deep and wiry, the prognosis is poor.

The Jin Gui Yao Lue classifies convulsion disease as a taiyang disease, so the basic principle of treatment is pattern differentiation according to taiyang disease.

Soft convulsion is treated with Gualou Guizhi Decoction. The Jin Gui Yao Lue states: "In taiyang disease, when the symptoms are complete, the body is rigid and stiff like a bird's neck, and the pulse is instead deep and retarded, this is convulsion; Gualou Guizhi Decoction governs it. Gualou Guizhi Decoction formula: Gualoulougen (Tianhuafen, Radix Trichosanthis) 2 liang, Guizhi (Ramulus Cinnamomi) 3 liang, Shaoyao (Radix Paeoniae) 3 liang, Gancao (Radix Glycyrrhizae) 2 liang, Shengjiang (Rhizoma Zingiberis Recens) 3 liang, Dazao (Fructus Jujubae) 12 pieces. Boil the six herbs in 9 sheng of water to yield 3 sheng; divide into three warm doses, to achieve slight sweating. If sweating does not occur, after a meal take warm congee to promote it."

This passage refers to the soft convulsion described above: the patient has fever and sweating, together with convulsion symptoms and a rigid body. Here the pulse being "instead deep and retarded" should be understood as somewhat slow and retarded. A retarded pulse is typical after sweating; if the patient cannot sweat, the pulse is either tight or wiry. Gualou Guizhi Decoction is Guizhi Decoction plus Gualoulougen. Gualoulougen is bitter-cold in nature, nourishes yin and moistens dryness, and is suitable for those with dry mouth and tongue. Its use is also similar to Guizhi Decoction: if the patient does not produce slight sweating after taking the medicine, warm congee is taken to assist sweating. Thus we should understand Zhang Zhongjing's soft convulsion as a type of taiyang wind-stroke disease accompanied by symptoms such as body rigidity.

Rigid convulsion is treated with Gegen Decoction. The original text in the Jin Gui Yao Lue reads: "In taiyang disease, without sweating but with scant urine, qi surging upward to the chest, lockjaw and inability to speak, about to develop rigid convulsion, Gegen Decoction governs it. Gegen Decoction formula: Gegen (Radix Puerariae) 4 liang, Mahuang (Herba Ephedrae, nodes removed) 3 liang, Guizhi (cortex removed) 2 liang, Shaoyao 2 liang, Zhigancao (honey-fried Radix Glycyrrhizae) 2 liang, Shengjiang 3 liang, Dazao 12 pieces. Crush the seven herbs; boil Mahuang and Gegen first in 7 sheng of water, reducing by 2 sheng and skimming the foam; add the other herbs and boil to 3 sheng; strain. Take one sheng warm, cover up to obtain slight sweating; no congee is needed; the remainder follows the taking-care and禁忌 of Guizhi Decoction."

Rigid convulsion is characterized by no sweating and scant urine, meaning the body's fluids cannot be properly excreted. Such patients must be treated with Gegen Decoction, which has a stronger sweating action than Guizhi Decoction. Gegen Decoction is actually Guizhi Decoction plus Mahuang and Gegen. Guizhi Decoction alone is insufficient to promote sweating, so Mahuang is added; Mahuang also promotes urination, thereby restoring normal excretion of body fluids. Gegen has an action similar to Guizhi Decoction in "resolving the muscle layer" and relieving rigidity and tension of the neck and back, and is one of the specific herbs for convulsion disease. Therefore for rigid convulsion patients, Zhang Zhongjing used the stronger Gegen Decoction.

Both rigid and soft convulsion are exterior patterns. There is also a convulsion that, because the exterior pattern was not treated, has transformed into an interior pattern. Once it has become an interior pattern, Chengqi Decoction must be used. The Jin Gui Yao Lue states: "In convulsion disease, with fullness of the chest, lockjaw, inability to lie flat on the mat, tense spasms of the feet, and inevitable gnashing of teeth (audible grinding of the teeth), Da Chengqi Decoction may be given. Da Chengqi Decoction formula: Dahuang (washed with wine) 4 liang, Houpo (炙, bark removed) half a jin, Zhishi (roasted) 5 pieces, Mangxiao 3 ge. Boil the latter two in 1 dou of water first to yield 5 sheng; strain; add Dahuang and boil to 2 sheng; strain; add Mangxiao and bring to a brief boil over low heat. Divide into two warm doses; stop taking once purgation occurs."

This convulsion is heat evil entering the interior and causing Yangming bowel-excess syndrome, so Zhang Zhongjing says Da Chengqi Decoction "may be given." Of course, here it is "may be given" rather than the "governs it" used for Gualou Guizhi Decoction and Gegen Decoction, indicating that this convulsion may also present as a Tiaowei Chengqi Decoction, Xiao Chengqi Decoction or even Da Chaihu Decoction pattern, depending on the patient's specific condition. Medication should stop once the patient's bowel movement becomes normal. How to distinguish the exterior and interior patterns of convulsion disease? It depends on whether the patient has teeth-grinding, foot spasms and inability to lie flat on the mat; if present, it is an interior pattern and must be treated with Chengqi Decoction.

This series of convulsion disease symptoms is very common clinically. Apart from tetanus convulsion, which is dangerous and unsuitable for TCM treatment, the rest of convulsion disease can be treated with TCM pattern differentiation. Moreover, western medicine has difficulty offering particularly effective symptomatic regimens for these symptoms; TCM pattern differentiation may work better.