Syncope is a frequently encountered urgent condition characterized by sudden fainting with temporary loss of consciousness.
Etiology and Pathology
Syncope may be due to a variety of causes, including disturbances in the activities of Qi or blood, emotional upset or postural changes. In Chinese medicine, according to the causative factors, syncope may be classified into the following categories: Qi syncope, blood (circulation) syncope, Phlegm syncope, Summer Heat syncope and food retention syncope. Qi and blood syncope, especially of the strength type, account for most of the cases.
Qi Syncope. In a person with constitutionally abundant Qi sudden emotional upset, such as anger, fright or terror, may induce abnormal ascent of Qi, which in turn blocks the clear orifices and induces syncope. Conversely, in a person with constitutionally deficient genuine Qi strong grief or sadness or overstrain may prevent pure Yang from ascending. This compromises nourishment of the mind and may precipitate syncope.
Blood Syncope. In a patient with constitutionally abundant liver-Yang rage can induce Qi and blood to move erratically. In such circumstances the abnormal ascent of Qi and blood may block the clear orifices, leading to syncope. Alternately, if blood is insufficient, whether due to chronic illness or to massive bleeding, then Qi and blood are unable to reach the clear orifices; in this situation, syncope can also ensue.
Phlegm Syncope. Obese persons often have Qi deficiency. Overindulgence by such a person in alcoholic drinks and greasy, spicy or sweet foods can easily injure the spleen and stomach. Dampness can then accumulate and give rise to Phlegm, and Phlegm can impede Qi movement. In such circumstances rage may cause Qi to move erratically. Phlegm then follows ascending Qi and can block the clear orifices, resulting in syncope.
Summer Heat Syncope. Summer Heat is a Yang evil. When it attacks the body it progresses rapidly. If it reaches the pericardium it may disturb the mind and induce loss of consciousness.
Food Retention Syncope. Improper diet may lead to food retention and disturbance of transportation. Impedance of Qi movement then induces a sensation of suffocation and syncope.
Thus, all pathological mechanisms leading to syncope contain two aspects: constitutional and emotional. The constitution aspect determines the susceptibility to certain pathogenic factors, and the emotional aspect induces dysfunction of the visceral organs, abnormal ascent of Qi blocking the clear orifices or failure of pure Yang to rise and nourish the clear orifices.
Clinical Manifestations and Key Points for Diagnosis
Typically, syncope comes abruptly with loss of consciousness and cold limbs. Often, there is an obvious precipitating factor, such as emotional distress, fright, fear or pain. There may also be one or more premonitory symptoms, such as dizziness, sudden facial pallor, sweating, nausea, dimming of vision, and weakness.
In mild cases, the patient regains consciousness in a short time. There may be some dizziness, weakness, fatigue and a dry mouth, but usually no significant residual symptom. In severe cases, syncope becomes coma, which may last many hours or days. Coma may occasionally lead to death.
Deficiency versus Strength. In an illness of evil strength, syncope is sudden. The face is flushed, respiration is coarse and jaws tight. There is fisting of the hands. Preceding syncope the voice is strong and respiration rushed. The tongue is red, with greasy yellow coating. The pulse is surging, large and forceful. In an illness of deficiency, syncope is preceded by dizziness and dimming of vision. The complexion is pale, voice soft and respiration weak. There is sweating and the limbs are cold. The tongue is pale or plump. The pulse is threadlike, feeble and forceless.
Qi versus Blood. In the strength type of Qi syncope liver Qi ascends abnormally in a person of strong physique. In addition to sudden fainting, there are coarse respiration, tight jaws, fisted hands, dizziness and headache. The tongue is red, with yellow coating. The pulse is deep and taut. In the strength type of blood syncope liver-Yang rises abnormally, with sudden hyperactivity of Yang-Qi and blood flowing upward along with Qi. In addition to sudden fainting, there are tight jaws, cold limbs, and a flushed face with purple lips or epistaxis. The tongue is cyanotic. The pulse is taut and forceful.
Causative Factors. The deficiency type of Qi syncope occurs mostly in a patient with constitutional weakness. There usually are precipitating conditions such as excessive fatigue, inadequate sleep, hunger or cold exposure. The deficiency type of blood syncope occurs mostly in a patient who has suffered massive blood loss. The strength type of Qi or blood syncope occurs mostly in a patient with strong physique and is intimately connected to strong emotional stimulation. Phlegm syncope occurs mostly in a patient who overindulges in fatty and sweet foods, is obese and whose body contains Dampness. Food retention syncope occurs most commonly following binge eating.
Strength Type of Qi Syncope
Main Symptoms. Sudden fainting precipitated by emotional stimulation, loss of consciousness, coarse respiration, tight jaws and fisted hands; or cold limbs. The tongue coating is thin and white. The pulse is deep and taut or deep and sunken.
Therapeutic Principle. Regulate Qi and release stagnation to open orifices.
Treatment. For resuscitation, force-feed Suhexiang Wan (Storax Pill). Follow with Wu Mo Yin Zi.
If there is much sputum causing impeded respiration, add bile-treated nanxing (Arisaema consanguineum), zhuli (Phyllostachys nigra) and beimu (Fritillaria) to eliminate sputum.
If there are dizziness and headache, with flushed face and red eyes, add gouteng (Uncaria) and shijueming (Haliotis) to calm the liver and suppress Yang.
For patients with a history of similar attacks, use such formulas as Xiao Yao San (Carefree Powder) as a preventive.
Deficiency Type of Qi Syncope
Main Symptoms. Weak constitution; precipitating symptoms such as overwrought emotions, excessive fatigue, hunger or intense pain; dizziness, fainting; pallid complexion; sweating, cold limbs; and weak respiration. The tongue is pale. The pulse is deep and infeeble.
Therapeutic Principle. Augment Qi and revive Yang.
Treatment. For resuscitation force-feed Shen Fu Tang (Ginseng-Aconitum Decoction). Alternately, inject Sheng Mai Solution (Pulse-Generating Solution) intravenously pre-prepared from Sheng Mai San (Pulse-Generating Powder).
Follow with Si Wei Hui Yang Yin (Four-Ingredients Yang-Rescue Drink). It has the following composition: renshen (Panax) 10 g, processed fuzi (Aconitum) 6g, ganjiang (Zingiber) 10 g, and gancao (Glycyrrhiza) 6g. Note: renshen is decocted first.
If sweating is profuse, add huangqi (Astragalus), baizhu (Atractylodes), longgu (fossil bone) and muli (Ostrea) to firm the exterior and stop sweating. (Note: longgu and muli have to be decocted first.)
Strength Type of Blood Syncope
Main Symptoms. Frequent dizziness; sudden fainting, often precipitated by emotional upset; tight jaws, flushed face, and purple lips. The tongue is dark red. The pulse is taut and forceful.
Therapeutic Principle. Open the orifices, mobilize blood and regulate Qi.
Treatment. For resuscitation force-feed Suhexiang Wan (Storax Pill). Alternately, use Qing Kai Ling intravenously by push or drip.
Follow with Tong Yu Jian (Stasis-Resolving Decoction). It has the following composition: danggui (Angelica) 10 g, honghua (Carthamus) 3g, shanzha (Crataegus) 6g, qingpi (Citrus tangerina) 10 g, wuyao (Lindera) 10 g, muxiang (Aucklandia) 10 g, xiangfu (Cyperus) 10 g, and zexie (Alisma) 10 g.
For agitation and irascibility, with dizziness and headache, add shijueming (Haliotis), gouteng (Uncaria), longdancao (Gentiana), juhua (Chrysanthemum) and shichangpu (Acorus) to calm the liver and the mind.
Deficiency Type of Blood Syncope
Main Symptoms. Sudden fainting, pallid complexion, lusterless lips, limb tremor, spontaneous sweating, cold limbs and weak respiration. The tongue is pale. The pulse is hollow or threadlike, rapid and forceless.
Therapeutic Principle. Augment Qi and nourish blood.
Treatment. For resuscitation force-feed Du Shen Tang (Lone Ginseng Decoction) or give Renshen Solution or Sheng Ma Solution by intravenous drip or push.
Follow with modified Renshen Yang Ying Tang (Ginseng Nutritive-Supporting Decoction). It has the following composition: renshen (Panax) 10 g, huangqi (Astragalus) 10 g, danggui (Angelica) 10 g, shudihuang (Rehmannia) 10 g, baishaoyao (Paeonia) 10 g, wuweizi (Schisandra) 10 g, baizhu (Atractylodes) 10 g, fuling (Poria) 10 g, yuanzhi (Polygala) 10 g, gancao (Glycyrrhiza) 10 g, rougui (Cinnamomum) 10 g, shengjiang (Zingiber) 10 g, dazao (Ziziphus) 10 g, andchenpi (Citrus tangerina) 10 g.
For spontaneous sweating and cold limbs, with weak respiration, add processed processed processed fuzi (Aconitum) and ganjiang (Zingiber) to warm Yang.
For dry mouth with insufficient fluids, add maimendong (Ophiopogon), shashen (Adenophora tetraphylla) and yuzhu (Polygonatum) to nourish Yin.
Summer Heat Syncope
Main Symptoms. Sudden fainting on a hot summer day; fever with cold limbs; and flushed facet. In some cases, there may be delirium. The tongue is red and dry. The pulse is surging and rapid.
Therapeutic Principle. Cool Summer Heat, augment Qi, open orifices and stimulate the mind.
Treatment. For resuscitation force-feed Niuhuang Qing Xin Wan (Gallstone Mind-Clearing Pill) or Zi Xue Dan (Purple-Snow Pill). Alternately, give Qing Kai Ling intravenously. General measures include moving the patient to a shaded and cool place, oxygen inhalation, intravenous fluids and an effective cooling measure.
Follow with Bai Hu Jia Renshen Tang (White Tiger plus Ginseng Decoction).
If there are convulsion and delirium, add lingyangjiao (Saiga tatarica), gouteng (Uncaria) and juhua (Chrysanthemum) to cool Heat, regulate the liver, dispel Wind and stop convulsion.
Main Symptoms. There is a history of habitual overindulgence in fatty and sweet foods, with much sputum. Sudden fainting precipitated by rage; gurgling in the throat with sputum; spitting of sputum or saliva; and coarse respiration. The tongue coating is white and greasy. The pulse is deep and slippery.
Therapeutic Principle. Mobilize Qi and eliminate Phlegm.
Treatment. Dao Tan Tang (Phlegm-Dissipating Decoction).
To enhance the formula’s actions to eliminate Phlegm and regulate Qi, add zisuzi (Perilla) and baijiezi (Brassica).
If Phlegm and Dampness have given rise to endogenous Heat, with viscid yellow sputum and greasy yellow tongue coating, add zhuli (Phyllostachys), zhizi (Gardenia) and huangqin (Scutellaria) to cool Heat and dissipate Phlegm.
Food Retention Syncope
Main Symptoms. Sudden fainting, suffocating sensation and epigastric fullness. The tongue coating is thick and greasy. The pulse is slippery and replete.
Treatment. If syncope occurs shortly after eating, induce vomiting with salt solution and follow with Shen Zhu San (Leaven-Atractylodes Powder) and Bao He Wan (Harmony-Preserving Pill). The combined composition is as follows: shanzha (Crateagus), shenqu (medicated leaven), laiprocessed processed fuzi (Raphanus), huoxiang (Agastache), cangzhu (Atractylodes lanced), houpo (Magnolia), sharen (Amomum), banxia (Pinellia), chenpi (Citrus tangerina) and fuling (Poria).