▲Zhou Zhongying, Master of Traditional Chinese Medicine (1928.6-2023.10)Zhou Zhongying, the first Master of Traditional Chinese Medicine, Chief TCM Physician at Jiangsu Provincial Hospital of Traditional Chinese Medicine. He has been engaged in clinical work in TCM for 70 years. He proposed new theories such as “Three Toxins Theory” and “Stagnation and Heat Theory”, which have shown significant efficacy. He introduced a new perspective on viral infectious diseases, stating that “the pathological center lies in Qi and Ying, with a focus on Ying and Blood”. In recent years, Zhou Zhongying has reviewed his clinical experience in dealing with externally contracted febrile diseases, combining his insights from TCM responses to SARS, severe influenza, etc., and published an article titled “Key Points in Differentiating and Treating Febrile Diseases”, proposing that “Heat, Spasm, Reversal, Closure, and Collapse are the five major syndromes of externally contracted febrile diseases”, and summarized the five key principles of differentiation and treatment: “Heat differentiation, Spasm observation of deficiency and excess, Reversal differentiation of cold and heat, Closure as heat phlegm stagnation, Collapse as Qi and Yin exhaustion”. This has significant academic implications for TCM’s response to acute externally contracted febrile diseases, but due to the overly concise content, it is not easy to understand its connotation. This article aims to elaborate on the connotation of the five major syndromes of externally contracted febrile diseases, and is presented as follows for the benefit of colleagues.
The Five Major Syndromes of Externally Contracted Febrile DiseasesHeat syndrome refers to a type of externally contracted acute febrile disease characterized primarily by fever. Among them, fever is a common symptom of externally contracted febrile diseases, i.e., a common syndrome; spasm, reversal, closure, and collapse are variations of externally contracted febrile diseases, closely related to the progression of the disease, prognosis, and outcome.● Heat Heat, as the foremost of the five major syndromes, is an essential manifestation of externally contracted febrile diseases, especially with high fever being the most common. Fever often persists throughout the course of the disease, representing the occurrence and ongoing state of the disease. The degree and characteristics of fever indicate the etiology and corresponding pathogenesis of the disease. High fever often suggests a severe condition, with the basic pathogenesis being the exuberance of pathogenic toxins, a struggle between righteous and evil, and mismanagement or untimely treatment often leading to variations that affect prognosis.For instance, the “Shang Han Lun” records numerous adverse outcomes caused by mismanagement of sweating, vomiting, or purging, leading to chest obstruction, fullness below the heart, and even accelerating the transmission of the six meridians. Persistent and lingering heat symptoms often indicate a more complex etiology and pathogenesis, posing challenges for treatment. This is frequently seen in certain severe infectious diseases or damp-heat conditions. Additionally, types of fever such as alternating cold and heat, afternoon tidal fever, fever that does not subside, fever worse at night, and night fever with early cooling all have specific implications for differentiation.● Spasm Spasm refers to the rigidity or convulsions of limbs, which can manifest as limb convulsions, clenched jaws, upward gaze, and neck stiffness, with severe cases showing opisthotonos. The occurrence of spasms is often caused by internal stirring of liver wind, marking a critical stage in the progression of externally contracted febrile diseases. Its mechanism involves the exuberance of heat toxins, stirring up liver wind, with wind and fire fanning the flames, scorching the tendons and meridians, or heat damaging body fluids, leading to malnourishment of tendons and meridians, ultimately resulting in rigidity or convulsions. In externally contracted febrile diseases, spasm syndromes are often divided into two types: heat exuberance stirring wind and yin deficiency generating wind. The heat that generates wind often originates from heart fire, lung fire, liver fire, or stomach fire; yin deficiency generating wind results from heat damaging yin fluids, leading to loss of nourishment for the tendons, causing internal stirring of wind. The former is more common in the early or critical stages of the disease, while the latter is more prevalent in the later stages of the disease.● Reversal Reversal is also a severe condition in the course of externally contracted febrile diseases, characterized by coldness of the limbs and a stage of severe coldness, with severe cases leading to fainting or loss of consciousness. The former is limb reversal, while the latter is syncope. The pathogenesis is often due to external pathogens invading internally, obstructing the flow of Qi, causing Qi to become chaotic, and the yin and yang energies to fail to connect smoothly, resulting in syncope. As stated in the “Shang Han Lun, Volume Six, Differentiating Reversal Syndrome and Pulse Diagnosis, Treatment Twelve”: “In all cases of reversal, the yin and yang energies do not connect smoothly, leading to reversal.” Additionally, prolonged illness can lead to damage to body fluids and Qi consumption, resulting in loss of yang energy and coldness of the limbs. Furthermore, excessive sweating can also lead to reversal, which should not be overlooked. The reversal syndrome in externally contracted febrile diseases differs from that in internal injuries, where internal injury reversal is often due to Qi reversal, blood reversal, or phlegm reversal.● Closure Closure is caused by the exuberance of pathogenic Qi, obscuring the mind. Externally contracted febrile diseases are caused by the invasion of the six excesses and epidemic Qi into the body. From the perspective of cold damage, cold transforms into heat, and closure syndromes often occur in the Yangming meridian; from the perspective of warm diseases (including epidemics), they often transform from Wei Qi to Ying and Blood, with closure syndromes frequently occurring in the Qi and Ying levels, and also in the Blood level. Therefore, whether in cold damage or warm diseases, the occurrence of closure syndromes is often due to heat exuberance. However, pure heat closure of the heart is rare, often resulting from heat damaging yin fluids, transforming fluids into phlegm, or heat scorching yin blood, leading to stasis, with heat, phlegm, and stasis intermingling, ultimately obscuring the heart. It is important to note that both closure and reversal syndromes exhibit clinical manifestations of impaired consciousness, such as confusion and loss of consciousness, but their pathogenesis differs. The former is due to tangible phlegm-heat and stasis-heat obscuring the heart, while the latter is primarily due to chaotic Qi flow, Qi stagnation, and stasis, with yin and yang failing to connect smoothly. The pathogenesis of the two differs and needs to be distinguished.● Collapse If pathogenic Qi is strong and righteous Qi continues to be depleted, once righteous Qi is exhausted, Qi cannot be contained internally, leading to a transition from closure to collapse, with continuous sweating, unclear consciousness, pale complexion, and weak breath, resulting in collapse syndrome. Collapse syndrome is the final stage of disease progression, and if not treated in time, the prognosis is dire. The etiology of externally contracted febrile diseases can be divided into cold and heat pathogens, but clinically, heat pathogens are more prevalent while cold pathogens are relatively rare. Even if cold pathogens are present, they often transform into heat internally, thus the critical stage of the disease often features heat toxins as the primary aspect of pathogenesis. On one hand, pathogenic heat harms body fluids, scorching liquids, leading to severe damage to yin fluids, resulting in a loss of yin; on the other hand, excessive consumption of bodily functions can lead to exhaustion, resulting in the loss of yang and the inability to contain Qi, leading to collapse syndrome.The emergence of the five major syndromes often represents the occurrence and exacerbation of the disease, leading to further complexity in pathogenesis, while also presenting new problems and challenges for treatment. Therefore, these five major syndromes, especially spasm, reversal, closure, and collapse, are critical conditions in the progression of externally contracted febrile diseases and must be given due attention. A thorough exploration of their occurrence and evolution patterns has significant theoretical significance and clinical value in improving related diagnostic and treatment levels.Case StudyA patient, a university student, was hospitalized on August 26, 1998, due to fever, cough, and chest pain at a local hospital. The Western medical diagnosis was severe pneumonia and pleuritis. Various antibiotics and supportive therapies were applied, but the fever did not subside, and respiratory distress ensued. Chest X-ray showed right-sided pneumothorax and bilateral pleural effusion. Blood culture indicated growth of Staphylococcus aureus and fungi. On September 30, toxic shock and multiple organ failure occurred. Zhou Zhongying was consulted.Symptoms included high fever, confusion, spasm, and wheezing, indicating a critical condition. The TCM diagnosis was closure syndrome, differentiated as phlegm-heat obstruction, obstructing lung Qi, internal invasion of the heart, stirring liver wind, and damaging yin and consuming Qi, leading to internal closure and external collapse. Treatment aimed to support righteousness and stabilize collapse, clear and transform phlegm-heat, pacify liver wind, and open the orifices to awaken the spirit, using multiple methods to stabilize collapse, open orifices, clear heat, calm wind, and alleviate wheezing. The prescribed medications included An Gong Niu Huang Wan, Zi Xue Dan, Ling Yang Jiao Fen, and Hou Zao San.Second Diagnosis:Heat toxins remained strong, with a tendency for righteous Qi to collapse externally, increasing the need for clearing and penetrating power, adding herbs such as Jin Yin Hua (Honeysuckle), Lian Qiao (Forsythia), Dan Zhu Ye (Lophatherum), and Qing Hao (Artemisia Annua).Third Diagnosis:The trend of severe symptoms was curbed, and the righteous Qi of external collapse was protected, leading to a turning point. Continued treatment focused on clearing, stabilizing collapse, opening orifices, and calming wind, with critical conditions alleviated, orifices gradually opening, and collapse symptoms stabilized.Fourth Diagnosis:The trend of pathogenic heat gradually eased, body temperature stabilized, consciousness cleared, with phlegm-heat, liver wind, and Qi and yin damage becoming the main contradictions, thus reducing the quantity of major heat-clearing herbs in the original formula and increasing the focus on pacifying liver wind, clearing and transforming phlegm-heat, and tonifying Qi and yin.Note:This case is a review by Zhou Zhongying, and the specific content is not detailed, but the specific process and principles of treatment are present. The patient was a university student, with a rapid onset of illness, quickly developing critical symptoms such as confusion and spasm, with a complex condition. There was both phlegm-heat and Qi obstruction, affecting the heart, liver, and lung, combined with Qi and yin damage. From the treatment perspective, the principle was to treat the symptoms urgently, focusing on stabilizing collapse and opening closure, while also clearing heat, calming wind, and alleviating wheezing, with clear priorities and significant efficacy. Once the internal closure and external collapse were curbed, the treatment could adapt to the symptoms, focusing on pacifying liver wind, clearing and transforming phlegm-heat, and tonifying Qi and yin for follow-up care. Zhou Zhongying emphasized that the more urgent and critical the condition, the more it reflects the characteristics of TCM differentiation and treatment, although the role of Western medical methods should not be excluded, we must not underestimate our own advantages. This case illustrates this point.
Important Disclaimer:
Due to individual differences in constitution and condition, the formulas and dosages in this case are only applicable to the specific condition of this patient at that time. Without TCM differentiation and diagnosis, do not replicate the prescriptions and dosages in this case. Readers in need should seek treatment at a regular hospital to avoid delaying their condition.
【Source: China Traditional Chinese Medicine News, content compiled from: “China Traditional Chinese Medicine News” November 5, 2021, Fifth Edition, authors: Department of Traditional Chinese Medicine, Henan Provincial People’s Hospital Zheng Zhipan, Nanjing University of Chinese Medicine Ye Fang, Zhou Xueping】Recommended Reading
