Discussion of Acute Deficiency Syndrome Theory and its Clinical Application

INTRODUCTION

The name “acute deficiency syndrome” has not been systematically put forward in traditional Chinese medicine (TCM), but there are records of its use in ancient medical books. For example, in the Internal Classic of Huangdi, there is a description of “acute deficiency syndrome” caused by acute diseases including “storm”, “stroke” and “syncope”. It is also recorded that “three deficiencies resulting in sudden death” (Lingshu·Suilu) and “three deficiencies fighting lead to the death of a violent illness” (Lingshu·Jiugong Bafeng). As mentioned in Zhang Zhongjing's Treatise on Cold Pathogenic Diseases, “direct attack” also belongs to the category of “acute deficiency syndrome”. Jingyue Quanshu·Jueni recorded: there are two signs of Qi syncope, which can be caused by Qi deficiency and Qi excess. Those who collapse due to Qi deficiency must have a dull appearance, a pale complexion, a slightly cold body, and a weak pulse. Blood loss, such as metrorrhagia, vomiting, or postpartum blood loss, will lead to Qi desertion, resulting in the sudden death of soldiers and servants. These are the dangerous symptoms of “acute deficiency syndrome”. It can be seen that the clinical manifestations of “acute deficiency syndrome” have been accurately described by physicians in past dynasties.

Since modern times, the occurrence of “acute deficiency syndrome” has been increasing in clinical practice, such as in cases of anaphylactic shock, septic shock, hemorrhagic shock, and fluid-loss shock.^[1]

PATHOLOGICAL MECHANISM

“Acute deficiency syndrome” refers to a pathological state in which the body's Yin and Yang, Qi and blood, and viscera functions are rapidly weakened due to pathogenic factors within a short period. It is often expressed as “healthy Qi deficiency and pathogen excessiveness”. The syndrome has characteristics of acute onset, rapid change, many complications, and critical illness that characterize it as “urgent, severe, deficiency” syndrome.^[2]

The pathological mechanisms of the common type of acute deficiency syndrome is detailed below.^[3–5]

Qi deficiency and Qi desertion

Insufficient generation of Qi or excessive dissipation of Qi will lead to Qi deficiency. The righteous Qi continues to decay, and the consumption of Qi will lead to the collapse of Qi, blood, and body fluids. This can also be seen in severe bleeding and profuse sweating, which lead to the syndrome of Qi deprivation caused by clear fluid depletion and blood depletion These are the main mechanisms of various desertion diseases. They can be observed in diseases such as sepsis, anaphylactic shock, etc.

Blood deficiency and blood depletion

The spleen failing to manage blood, the liver failing to store blood, and the stirring of blood due to intense heat can lead to extravascular bleeding. In the clinic this is common in hemoptysis, upper gastrointestinal bleeding, hematochezia, metrorrhagia, and other hemorrhagic diseases. This kind of blood depletion syndrome caused by massive bleeding in a short period is also a manifestation of “acute deficiency syndrome”.

Yin deficiency and Yin depletion

Yin deficiency can be caused by pyreticosis or miscellaneous illness for a long time, or due to five excessive emotional activities that cause the Yin fluid to be depleted and deficient. The main cause of Yin depletion is excessive fluid loss after severe vomiting and diarrhea. The characteristics of Yin depletion are excessive perspiration and warm, salty, sticky sweating, which is a dangerous sign of the disease. If treatment is not timely, it can lead to rapid death.

Yang deficiency and Yang depletion

Overeating cold foods (including cold and cool herbs), and the direct invasion of cold pathogens, leads to acute impairment of Yang Qi, where Yang deprivation occurs on the basis of Yang deficiency. In clinical practice, it is commonly seen in cardiac arrest, acute left heart failure, pediatric severe pneumonia, and shock.

TREATMENT PRINCIPLE

“Asthenia requiring tonification” is the treatment principle of “acute deficiency syndrome”. Tonifying the deficiency of Qi, blood, Yin, Yang, and the depletion of organs, is the treatment method for “acute deficiency syndrome”. Treatment methods can be divided into the tonifying method, warming method, astringing method, and others.^[6,7]

Tonifying method

The method of tonifying Qi is suitable for acute Qi deficiency syndrome, such as in fatigue, shortness of breath, asthma, pale complexion, loss of appetite, loose stool, feeble pulse, etc.

The method of tonifying blood is suitable for acute blood deficiency syndrome, such as in dizziness, tinnitus, deafness, palpitation, insomnia, pale facial complexion, thready-rapid pulse or thready-hesitant pulse, etc.

The method of tonifying Yin is suitable for acute Yin deficiency syndrome, such as in febrile diseases. Symptoms are as follows: dry mouth, dry throat, insomnia, constipation, osteopyrexia and fever, night sweating, red tongue with less tongue coating, thready-rapid pulse, etc.

The method of tonifying Yang is suitable for acute Yang deficiency syndrome, such as in chilliness and cold limbs, cold hidrosis, deficient asthma, soreness and weakness of the waist and knees, diarrhea, edema, pale-puffy tongue, deep-slow pulse, etc.

Warming method

The method of warming the middle for dispelling cold is suitable for cold pathogens that have directly invaded the internal organs. Symptoms are as follows: cold limbs, epigastric pain, vomiting, diarrhea, pale tongue, slow-deep pulse, etc.

The method of a warming channel for dispelling cold is suitable for cold evil stagnating meridians and unsmooth blood flow. Symptoms are as follows: cold pain in extremities, dark skin color, greenish complexion, ecchymosis of the tongue, thready-hesitant pulse, etc.

The method of reviving Yang for resuscitation is suitable for the acute decline of Yang Qi and for excess cold in the interior. Symptoms are as follows: deadly cold hands and feet, aversion to cold, crouching, dyspeptic diarrhea, dripping in a cold sweat, dying pulse, etc.

Astringent method

The method of consolidating the surface and arresting sweating is suitable for asthenia syndrome of the superficies, such as in excessive sweating syndrome.

The method of stopping diarrhea with astringents is suitable for spleen and kidney Yang failure that has resulted in acute diarrhea.

The method of astringent essence is suitable for acute urinary incontinence with kidney Qi deficiency and bladder dysfunction.

CASE PRESENTATION

A 44 year old woman suffered sudden cardiac arrest during hemorrhoidectomy on May 11, 2011. After cardiopulmonary resuscitation, a spontaneous heart rhythm recovered, but she lost consciousness and had no spontaneous breathing, as well as limb convulsions. The patient was transferred to the Intensive Medicine Department of Shanghai Changzheng Hospital (Shanghai, China) on May 12 for treatment. On admission, the patient had a high fever, confusion, and weak spontaneous breathing, which was assisted by a ventilator. Treatments for her symptoms, such as physical cooling, intracranial pressure reduction, anti-inflammatory and anti-epileptic drugs, and blood purification, were given. On May 17, the patient underwent an invasive tracheotomy for the purpose of mechanical ventilation. The patient was still in a deep coma, without spontaneous breathing, accompanied by a persistent high fever and limb convulsions. Due to her critical condition, she was transferred to Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine on May 20. On admission, the patient was in a coma, with weak spontaneous breathing, profuse sputum, thick yellow phlegm, and occasional facial and limb convulsions. Physical examination yielded the following findings: temperature 38.2 °C, heart rate 100 beats/min, blood pressure 126/70 mmHg, unconscious, unresponsive, mild edema of the conjunctiva, dry and wet rales in both lungs, reduced muscle tension, tendon hyperreflexia, red tongue, yellow-greasy tongue fur, and slippery-rapid pulse.

The patient was diagnosed as having cardiopulmonary resuscitation syndrome, severe sepsis, and secondary epilepsy. Syndrome differentiation in TCM was that of the “collapse syndrome”, that is, a sudden collapse of Yang Qi and the primordial spirit, marked by phlegm. For emergency treatment, Angong Niuhuang pills (one pill, three times per day), Antelope Horn powder (3 g each time, three times per day), Fuyuan Xingnao decoction (60 g of ginseng, 40 g of bile Arisaema, 30 g of rhubarb root and rhizome, etc.) were given. The Yangming meridian acupoints “Zusanli, Yinlingquan, Xuehai, Fuai, Dabao” were also selected for electro-a cupuncture treatment (twice per day), combined with coarse acupuncture treatment of the “Danzhong” acupoint (twice per day). Bronchoalveolar lavage was performed on the patient with Tanreqing injection. Glucocorticoids, antibiotics, and systemic physical cooling therapy were discontinued, and the dose of antiepileptic drugs was reduced. After treatment, the patient's symptoms improved significantly. On May 24, the patient's consciousness recovered completely. On May 25, the patient was able to answer questions and returned to spontaneous respiration. The ventilator and blood purification treatments were discontinued. On May 29, the patient was able to eat independently without a gastric tube, and was transferred to rehabilitation therapy.

This case is a typical case of treating “acute deficiency syndrome”, and its successful result benefitted from a Chinese medicine intervention. The key to the treatment of this case was cerebral resuscitation. If it had not been performed, the patient may have entered a vegetative state and the prognosis would have been extremely poor. In this case, Angong Niuhuang pill and Antelope Horn powder were used to treat high fever and epilepsy. Fuyuan Xingnao decoction was applied to expel phlegm, open orifices, awaken the spirit, and restore central nervous system function. Treatment of this case also innovatively adopted the TCM theory of “treatment for flaccidity aims at Yangming meridian”; that is, using acupuncture at the Yangming meridian and “Danzhong” acupoints to treat respiratory failure. For ventilator-associated pneumonia, bronchoalveolar lavage with Tanreqing injection was used to promote sputum drainage and reduce antibiotic resistance and mortality.

“Acute deficiency syndrome” is a syndrome in which Yin and Yang, Qi and blood, and viscera functions are rapidly weakened within a short period. Clinical treatment should always focus on rescuing the patient from collapse, and on strengthening and consolidating body resistance. Based on the tonifying method, drugs with great cold, great heat, great pungence, great bitterness, or poisonous properties can be used as appropriate. The normal doses of the drugs can also be exceeded to highlight efficacy. In the process of emergency treatment, the use of TCM injections can be used based on syndrome differentiation, which is not only in line with the theory of TCM, but also convenient, fast, and effective. “Acute deficiency syndrome” can be seen in the occurrence and development of various clinical acute and critical syndromes. Due to its acute onset, rapid change, multiple concurrent syndromes, critical condition, and poor prognosis, if treatment is not timely the condition is often life-threatening. Therefore, in the process of TCM syndrome differentiation, we are required to quickly diagnose the disease by comprehensive analysis of data gained by four diagnostic methods, grasp the main indication of the disease, accurately differentiate the syndrome, and treat it quickly.