From the Head to the Heart Nest
On Tingling and Numbness
From time to time I get inquiries from colleagues, especially those who were formerly my students, for advice on cases they are seeing. One condition I have been asked about a few times is neuropathy. Neuropathy is an interesting example of a condition that is often a presenting chief complaint in clinic, but which often doesn’t get taught as a primary pathocondition in schools. While neuropathy frequently involves pain, which may put it into the impediment (bì syndrome) chapter, or lack of use, which may lump it in with paralysis, it just as frequently involves neither of those, and the patient is most concerned about lack of sensation. In my “big three” clinical textbooks (Maciocia, 2022; Wu & Fischer, 1997; and Maclean et al., 2018), only Maclean et al. has a stand-alone section on numbness and paresthesia. Even in pre-modern texts that I have been looking at, numbness seldom occurs as a disease category in its own right.
I happened across a chapter on this condition in Lèi Zhèng Zhì Cái [Differentiation and Classification of Patterns and Treatments, 類證治裁, 1839] by Lín Pèiqín林佩琴. I was first introduced to this text by a brief mention in Scheid (2002) which characterized the book as "a text often cited as a forerunner of contemporary pattern diagnosis," so naturally I went looking for an e-copy. I decided to work on the chapter, and I’m posting the results here on the mulch, hopefully without too many misunderstandings and mistakes.
Má Mù: Definition and Etymology
Numbness and paresthesias are usually found in the disease category má mù 麻木. Má mù is defined in Wiseman (1998) as
“Loss of normal sensation in the skin and flesh. Numbness (Mù) is described as absence of itching or pain that is insensitive to pressure. Tingling (Má) is classically described as ‘bugs crawling in the flesh’, unrelieved by pressure.”
They go on to speculate that má, 麻, “hemp” may refer to the feeling of hemp fabric on the skin, where mù, 木, “wood” is metaphoric for lack of sensation. I am reminded of getting a shot of novocaine from my dentist, who told me to wait until my jaw felt “like a piece of wood” before the drilling would proceed. Wiseman (1998 & 2022) renders the term má mù as “numbness and tingling”, though the word order is reversed. I have decided to keep the word order intact, as “tingling and numbness”, as I find it less confusing.
麻木論治
Má Mù Lùn Zhì
Discussion of Tingling and Numbness
麻木，營衛滯而不行之症。《靈樞》云：衛氣不行，則為麻木。《素問》云：營氣虛則不仁，衛氣虛則不用，營衛俱虛則不仁且不用。如人坐久，壓著一邊，亦為麻木。東垣以為氣不行，當補肺氣。丹溪以麻為氣虛，木為濕痰敗血，於不仁中，確分為二。
Tingling and numbness is a pathocondition of stagnant and non-moving yíng [provisioning qì] and wèi [defense qì]. Líng Shū [Spiritual Pivot] says: Wèi qì’s inability to move results in numbness. Sù Wèn [Simple Questions] says: Yíng qì vacuity results in insensitivity, wèi qì vacuity results in loss of use, combined vacuity of yíng and wèi results in both insensitivity and loss of use. If a person sits for a long time, and there is pressure on one side, there will also be tingling and numbness. Dōngyuán believed that if the qì is not moving, one should supplement lung qì. Dānxī took tingling [má] to be qì vacuity, and numbness [mù] to be dampness, phlegm, and vanquished blood. Within [the category of] insensitivity, it is really divided into two.
Comment: The text refers to Lǐ Dōngyuán and Zhū Dānxī, two of the “four great masters” of the Sòng-Jīn-Yuán period.
蓋麻雖不關痛癢，只氣虛而風痰湊之，如風翔浪沸，木則肌肉頑痹，濕痰挾敗血，阻滯陽氣，不能遍運，為病較甚，俱分久暫治之。
Tingling, though, does not involve pain and itching, only qì vacuity and wind phlegm gathering together, like wind soaring, wandering, and churning. Numbness follows from stubborn impediment (bì) in the muscles and flesh; dampness and phlegm complicated by vanquished blood block the yáng qì, which is unable to spread and transport. The illness can become quite severe; it all can be separated into long term and short term treatment.
治麻以氣虛為本，風痰為標。用生薑為響導，枳殼開氣，半夏逐痰，羌活、防風散風，木通、威靈仙、白殭蠶行經絡。手臂用桑枝，足股用牛膝，病減用補中益氣湯，重加參、耆以固本。
Treat tingling using qì vacuity as the root, and wind-phlegm as the branch. Use Shēng Jiāng [Rz Zingiberis Recens] as a resonance conductor; Zhǐ Ké [Fr Aurantii] to open the qì; Bàn Xià [Rz Pinelliae] to expel phlegm; Qiāng Huó [Rz Notopterygii] and Fáng Fēng [Rx Saposhnikoviae], to scatter wind; Mù Tōng [Caulis Akebiae], Wēi Líng Xiān [Rx Clematidis], and Bái Jiāng Cán [Bombyx Batryticatus] to move the channels and network vessels. For the arm use Sāng Zhī [Rm Mori], for the leg use Niú Xī [Rx Achyranthis]. To reduce the disease use Bǔ Zhōng Yì Qì Tāng [Center-Supplementing Qì-Boosting Decoction], if it is serious add Rén Shēn [Rx Ginseng]; if [the patient is] elderly, one needs to secure the root.
治本以桂附為響導，烏藥、木香行氣，當歸、杞子、桃仁、紅花和血，穿山甲、牙皂通經絡，病減，用八珍湯以培虛。
Treat the root by means of Ròu Guì [Cx Cinnamomi] and Fù Zǐ [Rx Aconiti Lateralis Praeparata] as resonance conductors; Wū Yào [Rx Linderae] and Mù Xiāng [Rz Aucklandiae] to move qì; Dāng Guī [Rx Angelicae Sinensis], Qǐ Zǐ [Fr Lycii], Táo Rén [Sm Persicae], and Hóng Huā [Fl Carthami] to harmonize the blood, Chuān Shān Jiǎ [Squama Manitis] and Yá Zào [Fr Gleditsiae] to free the channels and network vessels. To reduce the disease, use Bā Zhēn Tāng [Eight Treasure Decoction] to bank up vacuity.
Comment: Though the text says “治本”, or “treat the root”, I suspect it may be a misprint, and should say “治木”, “treat numbness”. This allows the text to juxtapose the two characters, tingling and numbness, and the different pathomechanisms and treatments for each. Furthermore, in the formula section following the discussion, Bā Zhēn Tāng is listed as the formula to “治木” treat numbness (rather than “the root”).
此外如渾身麻木，衛氣不行者，神效黃耆湯。皮膚麻木，肺氣不行者，芍藥補氣湯加防風。肌肉麻木，營氣不行者，八仙湯。暑月麻木，熱傷元氣者，人參益氣湯。冷風麻痹，足屈不伸者，獨活寄生湯。腿足麻木，忽如火灼，屬濕熱下注。二妙丸加牛膝，不應，加肉桂。手臂麻，屬氣虛。補中益氣湯加桑枝、薑黃。
Besides this, in cases where there is tingling and numbness over the whole body [because] the wèi qì is not moving, Huáng Qí Tāng [Astragalus Decoction] has a miraculous effect. In cases of skin tingling and numbness, in which the lung qì is not moving, [use] Sháo Yào Bǔ Qì Tāng [Peony Qì-Supplementing Decoction] plus Fáng Fēng. In cases of tingling and numbness in the muscles and flesh, due to yíng qì not moving, [use] Bā Xiān Tāng [Eight Immortals Decoction]. In cases of summerheat tingling and numbness, with heat injuring the origin, [use] Rén Shēn Yì Qì Tāng [Ginseng Qì-Boosting Decoction]. In cases of cold and wind paralysis, in which the foot is bent and cannot stretch, use Dú Huó Jì Shēng Tāng [Pubescent Angelica and Mistletoe Decoction]. Tingling and numbness of the leg and foot which suddenly feels like fire burning, pertains to downpour of dampness and heat. [Use] Èr Miào Wán [Mysterious Two Pills] plus Niú Xī [Rx Achyranthis], if there is no response add Ròu Guì. Tingling of the heand and arm pertains to qì vacuity. [Use] Bǔ Zhōng Yì Qì Tāng plus Sāng Zhī and Jiāng Huáng [Rz Curcumae Longae].
Comment: Many of the formulas are unfamiliar to modern TCM students, and likely to students in the late imperial period as well. Lín provides a list with ingredients in a later section, which we will include.
立齋治何孟春，臂麻目淚，為氣虛有痰，用補中益氣湯，兼服六味丸而愈。十指麻木，屬胃中濕痰敗血。二術二陳湯加桃仁、紅花，少加附子行經。指尖麻，屬經氣虛。沈氏桑尖湯。面麻木，屬陽氣虛。牛皮膠煨化，和肉桂末厚塗之。口舌麻木，吐痰涎。止麻消痰湯。氣虛加人參，血虛加當歸身。
Lì Zhāi [aka Xuē Jǐ] treated Hé Mèngchūn [a government official in the Ming era], for tingling in the arm and eyes tearing due to qì vacuity with phlegm, using Bǔ Zhōng Yì Qì Tāng, given concurrently with Liù Wèi Wán [Six Flavor (Rehmannia) Pills] which cured it. Tingling and numbness in the ten fingers pertains to dampness, phlegm, and vanquished blood in the stomach. [Use] Èr Zhú Èr Chén Tāng [Two Atractylodes Two Aged Decoction] plus Táo Rén and Hóng Huā; if insufficient add Fù Zǐ to move the channel [qì]. Tingling in the fingertips pertains to channel qì vacuity, [use] Shěn Shì Sāng Jiān Tāng. Facial tingling and numbness pertains to yáng qì vacuity. Use Niú Pí Jiāo [Gelatinum Corii Bovis], simmer until dissolved, mix with Ròu Guì, powder and spread thickly [i.e. topical application]. Tingling and numbness in the mouth and tongue, spitting phlegm-drool. Use Zhǐ Má Xiāo Tán Tāng [Stop Tingling and Disperse Phlegm Decoction]. If there is qì vacuity add Rén Shēn, if blood vacuity add Dāng Guī Shēn.
合目則渾身麻木，開眼則止，東垣以為陽衰，濕伏陰分。用三痹湯去烏頭，加黃柏、蒼朮。腹皮麻痹，多煮蔥白食之即愈。
If closing the eyes results in tingling and numbness of the whole body, and opening the eyes makes it stop, Dōngyuán believed this to be yáng debilitation, with deep-lying dampness in the yīn aspect. Use Sān Bì Tāng [Three Impediment Decoction] removing Wū Tóu [Rx Aconiti], adding Huáng Bǎi [Cx Phellodendri] and Cāng Zhú [Rz Atractylodis]. Abdominal skin tingling and impediment, boil a lot of Cōng Bái [Blb Allii] to eat and it will be promptly cured.
Comment: Wiseman (2022) lists 麻痹 as “paralysis” but given the context of abdominal skin I just left the term as “tingling and impediment” as I am unsure as to how one could characterize the skin as being paralyzed.
一塊不知痛癢，遇陰寒益甚，屬痰挾死血，宜活血行氣。二陳湯加川芎、當歸、懷牛膝、韭汁，白芥子研末，蔥薑汁調敷外。專因血瘀，四物湯加韭汁、桃仁、紅花。專因氣滯，開結舒筋湯。有自頭麻至心窩而死，或自足心麻至膝蓋而死。麻骨方。
A lump with no sensation of pain or itching, and increases in severity when exposed to yīn cold, pertains to phlegm complicated by dead blood, one should quicken blood and move qì. Use Èr Chén Tāng plus Chuān Xiōng, Dāng Guī, Huái Niú Xī, Jiǔ Zhī [Succus Allii Tuberosi], Bái Jiè Zǐ [Sm Sinapis] grind to a powder, mix with Cōng [Bai] and Jiāng Zhī [Succus Zingiberis] and apply topically. If the specific cause is blood stasis, [use] Sì Wù Tāng plus Jiǔ Zhī, Táo Rén, Hóng Huā. If the specific cause is qì stagnation, [use] Kāi Jié Shū Jīn Tāng [Bind-Opening Sinew-Soothing Decoction]. If there is tingling from the head to the heart nest [center of the chest] and ends there, or tingling from the sole of the foot up to the knee and ends there, [use] Má Gǔ Fāng [Tingling Bone Formula].
Comment: It is interesting to see formulas such as modified Èr Chén Tāng used topically. Especially in our era, when much neuropathy is secondary to drug therapy using cytotoxic agents and so forth, it is interesting to consider the possibilities of administering formulas topically that might not be suitable for internal use due to drug-herb interactions. I’m no pharmacist, but I would venture that topical application allows the therapy to be much more localized while potentially limiting unwanted systemic effects.
婦人因悒鬱氣結，致發麻痹者，當舒郁。逍遙散加香附、川芎。《沈氏尊生書》曰：治麻木，須補助氣血，不可專用消散。方書有謂大指次指，忽然麻木不仁者，三年內須防中風。宜服地黃飲子，或十全大補湯加羌活、秦艽。若古法服愈風湯、天麻丸，開其元腑，漏其真液，適以招風取中，預防云乎哉。
In women [in whom] worry and depression cause the qì to bind, resulting in the development of paralysis, one should soothe depression. [Use] Xiāo Yáo Sàn plus Xiāng Fù [Rz Cyperi] and Chuān Xiōng. “Shěn Shì Zūn Shēng Shū” [Shěn Clan’s Book Honoring Scholars, 1773, by Shěn Jīnáo] says: Treating tingling and numbness, one must supplement and assist the qì and blood, but one should not use specifically dispersing and scattering [medicinals]. In prescription books there is what is called thumb and second finger with sudden tingling, numbness and insensitivity; one must guard against windstroke within three years. One should give Dì Huáng Yǐn Zi [Rehmannia Drink], or Shí Quán Dà Bǔ Tāng [Ten Great Supplementing Decoction] plus Qiāng Huó and Qín Jiāo [Rx Gentianae Macrophyllae]. If the old methods of taking Yù Fēng Tāng [Cure Wind Decoction] or Tiān Má Wán [Gastrodia Pills] open the original fǔ and possibly leak the true humors, it will proceed to beckon the wind to get in, which must be prevented.
麻木脈候
脈浮而濡，屬氣虛。關前得之，麻在上體；關後得之，麻在下體。浮而緩屬濕，為麻痹；緊屬寒，為痛痹。澀而芤，屬死血，為木，不知痛癢。
Tingling and Numbness Pulse Examination
If the pulse is floating and soggy, it is classified as qì vacuity . If it is obtained in front of the guān [middle position] there is tingling in the upper part of the body; if it is obtained behind the guān there is tingling in the lower part of the body. Floating and moderate is classified as dampness, causing tingling and impediment. Tight is classified as cold, causing painful impediment. Rough and hollow pertains to dead blood, causing numbness, lack of sensation, pain and itching.
Formulas in the Text
For the supplementary prescriptions section, I have not included the ingredients for the most commonly used formulas – the ones we all know. It is interesting to note the differences in formula choices between this source and Maclean et al. (2018). Between the two, there are a lot of options to consider.
附方
〔治麻〕 補中益氣湯
〔治木〕 八珍湯
〔衛氣〕 神效黃耆湯 參 耆 陳 芍 草 蔓荊子
〔肺氣〕 芍藥補氣湯 耆 芍 陳 草
〔營氣〕 八仙湯 八珍湯加 陳 夏 羌 防 柴胡 桂枝 秦艽 牛膝
〔清暑〕 人參益氣湯 耆（二錢） 參 草（各錢半） 白芍（七分） 柴胡（六分） 升麻（五分） 五味子（三十粒） 日二服。第二曰：耆（四錢） 紅花（三分半） 陳皮（五分） 澤瀉（三分） 亦日二服。第三曰：耆（三錢） 黃柏（六分） 陳皮（錢半） 升麻（一錢） 澤瀉（錢二分） 白芍（二錢半） 炙草（五分） 五味子（三十五粒） 亦日二服。
〔冷風〕 獨活寄生湯
〔濕熱〕 二妙丸
〔臂麻〕 六味丸
〔指麻〕 二術二陳湯 見二卷痰飲。[二術二陳湯 二術 苓 夏 陳 草]
〔指尖〕 桑尖湯 嫩桑尖（五錢） 漢防己（三錢） 當歸（二錢） 黃耆 茯苓（各一錢半） 威靈仙 秦艽（各一錢） 川芎 升麻（各五分） 加人參亦可。
〔口舌〕 止麻消痰湯 芩 連 苓 夏 蔞 桔 陳 枳 草 天麻 南星 細辛
〔合目〕 三痹湯 見本卷痹。[三痹湯 地 芍 歸 芎 參 耆 苓 草 防 獨 杜仲 牛膝 續斷 桂心 細辛 秦艽 姜 棗 水煎。]
〔行氣〕 二陳湯 見一卷中風。
〔血瘀〕 四物湯 見一卷中風。
〔氣滯〕 開結舒筋湯 紫蘇 陳皮 香附 烏藥 歸 芎 羌 夏 星 蒼朮（各八分） 桂枝 甘草（各四分）
〔頭足〕 麻骨湯 人糞燒灰，豆腐漿調服，即止。又方，川楝子燒灰為末，每服二五錢，酒下。
〔舒郁〕 逍遙散
〔中風〕 地黃飲子 熟地 桂心 附子 蓯蓉 巴戟 遠志 萸肉 石斛 麥冬 五味 薄荷 菖蒲 茯苓
〔補虛〕 十全大補湯 見一卷中風。
〔通治〕 愈風湯 羌活，甘草，防風，蔓荊子，川芎，細辛，枳殼，人蔘，麻黃，甘菊，薄荷，枸杞子，當歸，知母，地骨皮，黃耆，獨活，杜仲，吳白芷 ，秦艽，柴胡，半夏，前胡，厚朴，熟地黃，防己 (各2兩); 茯苓，黃芩，芍藥 (各 3兩); 石膏, 生地黃，蒼朮 (各4兩);桂枝1兩。
〔諸風〕 天麻丸 天麻 牛膝 萆薢 元參（各六兩） 當歸 羌活（各十兩） 杜仲（七兩） 熟地（一斤） 附子（三兩） 煉蜜為丸。
Supplementary Prescriptions
· Treat Tingling: Bǔ Zhōng Yì Qì Tāng
· Treat Numbness: Bā Zhēn Tāng
· Wèi Qì: Shén Xiào Huáng Qí Tāng: Rén Shēn, Huáng Qí [Rx Astragali], Chén Pí (Pc Citri Reticulatae), Bái Sháo [Rx Paeoniae Alba], Gān Cӑo [Rx Glycyrrhizae], Màn Jīng Zĭ [Fr Viticis]
· Lung Qì: Sháo Yào Bǔ Qì Tāng: Huáng Qí, Bái Sháo, Chén Pí, Gān Cӑo
· Yíng Qì: Bā Xiān Tāng: Bā Zhēn Tāng plus chén pí, bàn xià, Qiāng Huó, Fáng Fēng, Chái Hú [Rx Bupleuri] Guì Zhī [Rm Cinnamomi], Qín Jiāo, Niú Xī
· Clear Summerheat: Rén Shēn Yì Qì Tāng: Huáng Qí (2 qián) Rén Shēn, Gān Cӑo (Each 1.5 qián), Bái Sháo (7 fēn), Chái Hú (6 fēn), Shēng Má [Rz Cimicifugae] (5 fēn), Wǔ Wèi Zi [Fr Schisandrae] (30 pieces) take twice in a day. Day two: Huáng Qí (4 qián), Hóng Huā [Fl Carthami] (3.5 fēn) Chén Pí (5 fēn), Zé Xiè [Rz Alismatis] (3 fēn), also take twice in a day. Day 3: Huáng Qí (3 qián), Huáng Bǎi [Cx Phellodendri] (6 fēn), Chén Pí (1.5 qián), Shēng Má (1 qián) Zé Xiè (1.2 qián), Bái Sháo (2.5 qián), Zhì Cǎo (5 fēn), Wǔ Wèi Zi (30 pieces), also take twice in one day.
· Cold Wind: Dú Huó Jì Shēng Tāng
· Damp Heat: Èr Miào Wán
· Arm Tingling: Liù Wèi Wán
· Finger Tingling: Èr Shù Èr Chén Tāng. [This is Èr Chén Tāng plus Cāng Zhú [Rz Atractylodis] and Bái Zhú [Rz Atractylodis Macrocephalae]]
· Fingertip: Sāng Jiān Tāng: Nèn Sāng Jiān [Extremitas Mori Tener] (5 qián); Hàn Fáng Jǐ [Rx Stephaniae] (3 qián); Dāng Guī (2 qián); Huáng Qí, Fú Líng (each 1.5 qián), Wēi Líng Xiān [Rx Clematidis], Qín Jiāo (each 1 qián); Chuān Xiōng, Shēng Má (each 5 fēn); one can also add Rén Shēn.
· Mouth and Tongue:: Zhǐ Má Xiāo Tán Tāng : Huáng Qín [Rx Scutellariae Baicalensis], Huáng Lian [Rz Coptidis], Fú Líng, Bàn Xià, Guā Lóu [Fr Trichosanthis], Jú Pí, Chén Pí, Zhǐ Cǎo, Tiān Má [Rz Gastrodiae], Nán Xīng [Rz Arisaematis], Xì Xīn [Herba Asari]
· Closed Eyes: Sān Bì Tāng: Dì Huáng [Rx Rehmanniae], Bái Sháo, Dāng Guī, Chuān Xiōng, Rén Shēn, Huáng Qí, Fú Líng, Gān Cǎo, Fáng Fēng, Dú Huó [Rx Angelicae Pubescentis], Dù Zhòng [Cortex Eucommiae], Niú Xī, Xù Duàn [Rx Dipsaci], Guì Xīn [Cx Cinnamomi], Xì Xīn, Qín Jiāo, Shēng Jiāng, Dà Zǎo [Fr Jujubae], decoct in water.
· Move Qì: Èr Chén Tāng
· Blood Stasis: Sì Wù Tāng
· Qì Stagnation: Kāi Jié Shū Jīn Tāng: Zǐ Sū [Fm Perillae], Chén Pí, Xiāng Fù [Rz Cyperi], Wū Yào [Rx Linderae], Dāng Guī, Chuān Xiōng, Qiāng Huó, Bàn Xià, Nán Xīng, Cāng Zhú (each 8 fēn); Guì Zhī, Gān Cǎo (each 4 fēn)
· Head and Foot: Má Gǔ Tāng: Burn human excreta to ashes, mix with Dòu Fu Jiāng [Lac Sojae/ soy milk] and take, until [symptoms] stop. Another prescription, Chuān Liàn Zi [Fr Toosendan], burn to ashes and pulverize, every day take 2 [doses] of 5 qián, chased with wine.
· Soothe Depression: Xiāo Yáo Sǎn
· Wind Strike: Dì Huáng Yǐn Zi [Rehmannia Drink]: Shú Dì, Guì Xīn, Fù Zǐ, Cōng Róng [Herba Cistanches], Bā Jǐ [Rx Morindae], Yuǎn Zhì [Rx Polygalae], Yú Ròu [Fr Corni], Shí Hú [Hb Dendrobii], Mài Dōng [Tuber Ophiopogonis], Wǔ Wèi, Bò Hé [Hb Menthae], Chāng Pú [Rz Acori], Fú Líng.
· Supplement Vacuity: Shí Quán Dà Bǔ Tāng
· Freeing Treatment: Yù Fēng Tāng: Qiāng Huó, Gān Cǎo, Fáng Fēng, Màn Jīng Zi, Chuān Xiōng, Xì Xīn, Zhǐ Ké, Rén Shēn, Má Huáng, Gān Jú [Fl Chrysanthemi], Bò Hé, Gǒu Qǐ Zi, Dāng Guī, Zhī Mǔ [Rz Anemarrhenae], Dì Gǔ Pí, Huáng Qí, Dú Huó, Dù Zhòng, Wú Bái Zhǐ [Rx Angelicae Dahuricae], Qín Jiāo, Chái Hú, Bàn Xià, Qián Hú [Rx Peucedani], Hòu Pò [Cx Magnoliae), Shú Dì Huáng, Fáng Jǐ (each 2 liǎng); Fú Líng, Huáng Qín, Sháo Yào (each 3 liǎng); Shí Gāo, Shēng Dì Huáng, Cāng Zhú (each 4 liǎng), Guì Zhī (1 liǎng).
· All Wind: Tiān Má Wán: Tiān Ma, Niú Xī, Bì Xiè, Yuán Shēn [Rx Scrophulariae] (each 6 liǎng); Dāng Guī, Qiāng Huó (each 10 liǎng); Dù Zhòng (7 liǎng), Shú Dì (1 jīn); Fù Zǐ (3 liǎng); process with honey to make pills.
Note: this publication is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have.
References
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