Patient Y, a 41-year-old woman, was an employee of a courier company. She had a history of hypertension and was taking medication regularly.
At 2:00 a.m. on June 25, 2020, while on duty unloading cargo, she suddenly developed impaired consciousness accompanied by fever. There were no convulsions or vomiting. Her coworkers immediately called 120, and she was taken to hospital for treatment. Three hours later, she arrived at the emergency department of a tertiary Grade A hospital in Shenzhen. Her temperature was 41°C. A chest CT scan revealed no abnormalities. She was immediately transferred to the intensive care unit (ICU).
On admission, her vital signs were as follows: temperature 38.3°C, heart rate 134 beats/min, respiratory rate 38 breaths/min, oxygen saturation 90%, and blood pressure 111/68 mmHg. She was comatose and unable to vocalize. Her limbs were in hyperextension, and she did not open her eyes in response to painful stimuli. Her Glasgow Coma Scale (GCS) score was 5. Her four limbs were warm.
Further investigations indicated impaired liver, kidney, and cardiac function. The specific findings were as follows: serum aspartate aminotransferase (AST) 149 U/L, total serum creatine kinase 7,152 U/L, cardiac creatine kinase 80.7 U/L, serum alanine aminotransferase (ALT) 76 U/L, and serum creatinine 135 μmol/L. A complete blood count showed a white blood cell count of 4.93 × 10⁹/L, with neutrophils accounting for 71.4%. A head CT scan revealed no abnormalities.
Admission diagnosis: Fever and impaired consciousness. Heatstroke (hyperthermia syndrome) was considered the most likely cause.
July 2 (Thursday): The patient was on the eighth day of coma. After obtaining the hospital’s approval, the company’s management asked me to provide a consultation.
On examination, both eyes were open with a fixed gaze. The pupils were dilated, and the pupillary light reflex was absent. Muscle tone was increased. She was not sweating (ice packs were being applied) and had no fever, although the attending physician reported a mild fever. There was no vomiting, and urination and defecation were normal. The pulse was deep, wiry, and rapid. As she was on a ventilator, the tongue presentation could not be assessed.
The pattern corresponded to jìng (痉, tetany) and yē (暍, summer-heat disease) as described in the Jīn Guì Yào Lüè. Later generations referred to this as “summer-heat wind” (shǔ fēng 暑风) or “summer-heat collapse” (shǔ jué 暑厥).
I provisionally prescribed Gě Gēn Tāng combined with Bái Hǔ Jiā Rén Shēn Tāng.
Prescription: Gě Gēn 60g, Guì Zhī 15g, Bái Sháo 15g, Má Huáng 15g, Xī Yáng Shēn 30g, Huā Fěn 30g, Shí Gāo 90g, Zhī Mǔ 20g, Gān Cǎo 20g.
July 3 (Friday): Due to a delay at the pharmacy in decocting the medicine, the patient only began taking it today. She had taken two doses, and her heart rate fluctuated around 120 beats/min. She had not passed stool and remained unconscious.
After consulting with the ICU attending physician, we agreed that, to facilitate dosage adjustments, the company would arrange delivery of the medicine directly from the following day.
Prescription:
Gě Gēn 90g (decoct first for 20 minutes), Má Huáng 20g (decoct first for 20 minutes), Guì Zhī 20g, Bái Sháo 45g, Dà Zǎo 15g, Gān Cǎo 20g, Máng Xiāo 10g (added to the finished decoction), Dà Huáng 15g (added near the end of decoction), Hòu Pò 20g, Zhǐ Shí 20g, and three slices of Shēng Jiāng.
Add four bowls of water. First decoct Gě Gēn and Má Huáng for 20 minutes, then add the remaining herbs and continue decocting until one bowl remains. Add Dà Huáng near the end and decoct for another three minutes. Reduce the decoction to slightly more than half a bowl, add half of the Máng Xiāo, and stir until dissolved. Transfer it to an insulated flask.
Next, decoct the herbs again in three bowls of water until slightly more than half a bowl remains. Add the remaining Máng Xiāo and transfer the decoction to a second insulated flask.
July 4 (Saturday): After adjusting the prescription to combine Gě Gēn Tāng with Dà Chéng Qì Tāng, the patient had taken two doses but had still not passed stool. All other symptoms remained unchanged.
The revised prescription was as follows:
Gě Gēn 90g (decoct first for 20 minutes), Má Huáng 25g (decoct first for 20 minutes), Guì Zhī 20g, Bái Sháo 45g, Dà Zǎo 15g, Gān Cǎo 20g, Máng Xiāo 10g (added to the finished decoction), Dà Huáng 15g (added near the end of decoction), Hòu Pò 20g, Zhǐ Shí 20g, and three slices of Shēng Jiāng. One daily dose.
July 5 (Sunday): At 3:00 p.m., the attending physician called to report that the patient had taken one dose of Chinese medicine today. Her consciousness had begun to recover, and she responded when called. Her heart rate had not increased significantly, and she had passed stool once.
I instructed them to continue with the original prescription but increase Má Huáng to 35g and administer another dose overnight.
Prescription:
Gě Gēn 90g (decoct first for 20 minutes), Má Huáng 35g (decoct first for 20 minutes), Guì Zhī 30g, Bái Sháo 45g, Dà Zǎo 15g, Gān Cǎo 20g, Máng Xiāo 20g (added to the finished decoction), Dà Huáng 15g (added near the end of decoction), Hòu Pò 20g, Zhǐ Shí 20g. Two doses, with one dose reserved for the following day.
July 6 (Monday): At 11:00 a.m., the attending physician called to report that the patient’s consciousness had cleared and her pupils had begun to respond to light. Her bowel movements were now regular. She still had a low-grade fever, and her heart rate was 110 beats/min.
I visited the hospital again in the afternoon to examine her in person. She could grip with her hands and blink her eyes, and she responded to verbal commands. However, she could not yet move her lower limbs or protrude her tongue.
Prescription: Gě Gēn 90g (decoct first for 20 minutes), Má Huáng 35g (decoct first for 20 minutes), Guì Zhī 30g, Bái Sháo 25g, Dà Zǎo 15g, Gān Cǎo 20g, Máng Xiāo 20g (added to the finished decoction), Dà Huáng 15g (added near the end of decoction), Hòu Pò 20g, Zhǐ Shí 20g, and Shí Gāo 90g (wrapped in cloth). Four doses, with two daily doses administered four times throughout the day and night.
July 9 (Thursday): The attending physician called to report that the patient had been taken off the ventilator. Her mental state was approximately the same as it had been two days earlier. She had passed stool several times but continued to have a low- to moderate-grade fever.
The following prescription was prepared for the next day:
Gě Gēn 90g (decoct first for 20 minutes), Má Huáng 35g (decoct first for 20 minutes), Guì Zhī 30g, Bái Sháo 25g, Dà Zǎo 15g, Gān Cǎo 20g, Chái Hú 25g, Huáng Qín 15g, Dǎng Shēn 30g, Zhì Bàn Xià 25g, and Shí Gāo 90g (wrapped in cloth). Four doses, with two daily doses administered four times throughout the day and night.
July 10 (Friday): In the afternoon, the patient’s workplace called and reported: “The patient’s consciousness is reasonably good at present. During the day, she opens her eyes spontaneously, but she is still weak throughout her body. There is some pulmonary infection. The hospital is concerned about medication safety, so today’s medicine could not be delivered in the afternoon. The attending physician suggests sending him the prescription so that the hospital can arrange for the medicine to be decocted and administered.”
The following prescription was prepared for the next day:
Má Huáng 25g, Běi Xìng 15g, Zhī Mǔ 25g, Chái Hú 25g, Huáng Qín 15g, Dǎng Shēn 30g, Dà Zǎo 15g, Gān Cǎo 15g, and Shí Gāo 60g.
Two doses, to be taken over the following two days, twice daily.
July 12 (Sunday): The patient’s company called and reported: “At 3:00 p.m., she was transferred to a general ward. Overall, her recovery has been quite good. The functions of all her organs have returned to normal, and her consciousness is clear. She can communicate normally and drink a little rice porridge. There is phlegm in her throat. Regarding neurological sequelae, the doctors’ current assessment is that there are no major problems. We will have to see how her subsequent rehabilitation progresses.”
Original Commentary
In the Jīn Guì Yào Lüè, tetany (jìng 痉), dampness (shī 湿), and summerheat (yē 暍) are grouped together in one chapter, which has profound clinical significance. Yē refers to summerheat. Excessive heat damages Yin and consequently gives rise to convulsive rigidity.
The manifestations of jìng include “clenched jaws, the body unable to settle onto the bed, and the feet in spasmodic contraction” and “the jaws clenched so that speech is impossible.” In modern terminology, these manifestations correspond to cerebral edema, coma, and increased muscle tone.
At such a time, treatment should not be confined to treating summer-heat; it must address the immediate condition. Tetany accompanied by jaw clenching is classified as gāng jìng (刚痉, hard tetany).
Treatment should aim to open the orifices and awaken the brain. Master Zhòngjǐng used máhuáng rather than Ān Gōng Niú Huáng Wán, and urgent purgation rather than simply clearing heat.
This is comparable to the three indications for urgent purgation in the Shāng Hán Lùn, including “ unclear vision and disharmony of the eyes.” In these cases, bowel movements are not the sole diagnostic criterion. Although the symptoms differ, the underlying principle is the same.
The patient had a history of hypertension and a relatively rapid heart rate. Initially, I had some reservations about using máhuáng, so I began with 15g, then increased it to 20g, and subsequently to 25g. When the patient’s consciousness began to recover, I took advantage of the improvement and continued administering the medicine intensively throughout the day and night.
The dose was eventually increased to 35g, making the total daily dose equivalent to 70g. máhuáng’s effects in opening the orifices, sustaining life, and restoring consciousness were truly remarkable!
(Recorded in Huáng Shìpèi’s Jīngfāng Lineage and Clinical Records.)
Commentary
Under the miscellaneous treatment formulas in the Jīn Guì Yào Lüè, there is a formula called Huán Hún Tāng (还魂汤, Restoring the Soul Decoction):
“Decoct máhuáng, xìngrén, and gāncǎo into a decoction and administer it in divided portions for swallowing. It treats all forms of sudden collapse caused by external disturbance.”
The term gǎn wǔ (感忤) refers to sudden loss of consciousness in which the person becomes unresponsive.
In the Qiān Jīn Fāng, this formula also contains Guì Xīn at a dose of two liǎng. It is essentially Má Huáng Tāng. Its indications are described as follows: “It governs sudden collapse, ghost-strike, flying corpse, and other conditions in which qì suddenly ceases, consciousness is lost, and there may be no palpable pulse. The jaws are clenched and cannot be opened; remove the teeth and administer the decoction.”
This suggests that máhuáng has effects such as awakening the brain and stimulating physiological activity. It may be used to treat coma, excessive sleepiness, fatigue, slowed thinking, and mental disorders.
Although the original Má Huáng Tāng was not used in this case, Gě Gēn Tāng, which also belongs to the máhuáng formula family, was employed. Gě Gēn Tāng treats stiffness of the neck and upper back, as well as “clenched jaws and inability to speak” caused by summer-heat induced tetany.
The original commentary’s interpretation—that the patient’s condition involved cerebral edema, coma, and increased muscle tone—is consistent with the clinical presentation.
The treatment also incorporated Dà Chéng Qì Tāng, which likewise has consciousness-restoring effects. In the Shāng Hán Lùn, it is used to treat “yángmíng disease with delirious speech,” “talking to oneself as though seeing ghosts,” and severe cases in which the patient suddenly becomes unable to recognize people, picking at bedclothes, fear and disquietude, slight panting, and forward-staring eyes. It is also used for “cold damage that has lasted for six or seven days, with unclear vision and disharmony of the eyes.”
The therapeutic approach, however, is not simply to clear heat. Rather, it purges accumulated heat in the yángmíng bowel.
The patient had been in a coma due to heatstroke for more than ten days, and her condition was extremely serious. To use Jīngfāng to revive her vital responsiveness under such circumstances was no small achievement.
