4.4 Inquiry I: The Ten Questions, Fever and Chills, Sweating, and Pain

4.4 Inquiry I: The Ten Questions, Fever and Chills, Sweating, and Pain

Inquiry (Wen Zhen) is the systematic elicitation of the patient's subjective symptoms, illness chronicity, sensations of temperature, pain patterns, and vegetative bodily functions. In the Ming Dynasty medical treatise Jing Yue Quan Shu (Complete Works of Jingyue), the physician Zhang Jing-yue organized clinical questioning into the famous Song of the Ten Questions (Shi Wen Ge):

"First ask of chills and fever, second ask of sweat; Third ask of head and body, fourth ask of stool and urine; Fifth ask of food and drink, sixth ask of chest and abdomen; Seventh ask of deafness, eighth ask of thirst; Ninth ask of past diseases, tenth ask of causes; In women, inquire of menses and pregnancy; In children, inquire of measles and fright."

Modern board examination questions systematically test these ten clinical inquiries to differentiate Zang-Fu, Eight Principles, Six Stages, and Four Levels patterns. Always begin with the presenting complaint: when and how it started, where it is, what makes it better or worse, and how it has changed. Then work through the questions as a review of systems. This section covers the first three questions (chills and fever, sweating, head and body); Section 4.5 covers the rest.

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Question 1: Chills and Fever (Han Re)

Inquiry into thermal sensations evaluates the conflict between Vital Qi (Zheng Qi) and Pathogenic Factors (Xie Qi), distinguishing exterior from interior and full from empty patterns.

                         [ THERMAL PATTERN DIFFERENTIATION ]
                                         |
     +-------------------+---------------+-------------------+-------------------+
     |                   |                                   |                   |
[SIMULTANEOUS]     [ALTERNATING]                     [HIGH FEVER ONLY]     [TIDAL FEVER]
Chills + Fever     Chills & Fever                    No Aversion to Cold   Afternoon Peak
     |                   |                                   |                   |
Exterior Invasion  Shaoyang Stage                    Yangming Full Heat    Yin Deficiency
(Taiyang Stage)    (Half-Exterior/Half-Interior)     (Four Greats)         (Empty Heat)

Clinical Classifications

A. Simultaneous Aversion to Cold and Fever (E Han Fa Re)

• Diagnostic Significance: Pathognomonic for an Exterior Pattern (Biao Zheng). Pathogenic Wind, Cold, or Heat invades the superficial skin and muscle layers, obstructing the circulation of Defensive Qi (Wei Qi). Because Wei Qi cannot warm the exterior, the patient experiences chills; because Wei Qi fights the pathogen, fever occurs.
• Wind-Cold Exterior: Severe aversion to cold, mild fever, absence of sweating, occipital headache, floating and tight pulse (Fu Jin).
• Wind-Heat Exterior: Higher fever, mild aversion to wind/cold, slight sweating, sore swollen throat, floating and rapid pulse (Fu Shu).

B. Alternating Chills and Fever (Han Re Wang Lai)

• Diagnostic Significance: Pathognomonic for a Shaoyang Pattern (Half-Exterior, Half-Interior / Ban Biao Ban Li) or Malaria (Nue Ji). The pathogen is trapped between the superficial Taiyang and interior Yangming layers. When the pathogen pushes inward toward the interior, chills occur; when Vital Qi pushes the pathogen outward toward the surface, fever erupts. Accompanied by a bitter taste in the mouth, dry throat, blurred vision, and a wiry pulse (Xian Mai).

C. High Fever with No Aversion to Cold (Zhuang Re)

• Diagnostic Significance: Pathognomonic for Yangming Interior Full Heat (Qi Level Heat). The pathogen has fully penetrated the interior and transformed into heat. Characterized by the classic Four Greats (Si Da): Great Fever, Great Thirst (demanding copious cold water), Great Sweat, and a Great/Surging Pulse (Hong Mai).

D. Tidal Afternoon / Evening Fever (Chao Re)

Fever that arrives predictably at a specific time each day, like the ocean tide.

• Yin Deficiency Tidal Fever (Yin Xu Chao Re): Low-grade fever emerging in the late afternoon or evening, accompanied by night sweats, five-palm heat, malar flush, and a red peeled tongue. Deficient Yin fails to balance Yang during the Yin hours of the day.
• Yangming Fu Organ Tidal Fever (Yangming Fu Chao Re): High fever peaking predictably between 3:00 PM and 5:00 PM (the Shen period, the late-afternoon tidal fever that the Shang Han Lun associates with Yangming), accompanied by severe abdominal pain aggravated by pressure, constipation with impacted stools, delirium, and a deep, full, forceful pulse.

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Question 2: Sweating (Han)

Sweat is the fluid of the Heart and originates from body fluids (Jinye) vaporized through the pores (Qi Men) by Yang Qi.

Clinical Classifications of Sweating

• Absence of Sweating in Exterior Conditions: Indicates Exterior Wind-Cold (Excess Exterior / Taiyang Shang Han). Pathogenic Cold contracts the skin pores, trapping Wei Qi and preventing perspiration.
• Sweating with Fever in Exterior Conditions: Indicates Exterior Wind-Heat or Exterior Wind-Cold Deficiency (Taiyang Zhong Feng), where Wei Qi is weak and cannot secure the pores.
• Spontaneous Daytime Sweating (Zi Han): Sweating occurs continuously during the day and worsens with slight physical exertion, accompanied by pale face and fatigue. Caused by Qi Deficiency (specifically Lung and Wei Qi deficiency failing to hold the pores closed).
• Night Sweating (Dao Han): Sweating occurs strictly during sleep, waking up drenched, and ceases immediately upon waking. Caused by Yin Deficiency. During sleep, Wei Qi retreats into the interior Yin organs; empty heat vaporizes internal fluids through the unprotected pores.
• Profuse Cold, Oily, Bead-Like Sweat (Jue Han): Cold, viscous sweat streaming down like pearls during acute physical collapse. Indicates Collapse of Yang (Wang Yang) or Collapse of Yin (Wang Yin); an extreme medical emergency.
• Localized Sweating:
  • Sweating Only on the Head: Upper Burner Heat, or Middle Burner Damp-Heat steaming upward.
  • Sweating Only on the Palms and Soles: Yin deficiency with Empty Heat, or Stomach and Spleen Heat.
  • Hemilateral Sweating (One Side of the Body): Obstruction of Qi and Blood in the channels, or impending Wind-Stroke.

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Question 3: Head and Body (Tou Shen)

Headache Localization by Channel Distribution

Nature and Characteristics of Body Pain

• Distending Pain (Zhang Tong): Feeling of fullness and stretching; moves from place to place. Indicates Qi Stagnation.
• Stabbing, Fixed Pain (Ci Tong): Sharp, lancinating, localized pain that does not move; worse at night and worse with pressure. Indicates Blood Stasis.
• Heavy Pain (Zhong Tong): Pain accompanied by a sensation of heaviness, numbness, or limb swelling; head feels wrapped tightly in a wet towel. Indicates Dampness.
• Cold Pain (Leng Tong): Deep ache relieved by warmth and aggravated by cold. Indicates Interior Cold or Yang deficiency.
• Dull, Lingering Pain (Yin Tong): Mild, continuous ache relieved by manual pressure, rest, and warmth. Indicates Deficiency of Qi, Blood, or Yin.

Bi Syndrome (Painful Joint Obstruction)

• Wandering Bi (Xing Bi - Wind): Migrating joint pain that wanders from joint to joint without fixed location.
• Painful / Fixed Bi (Tong Bi - Cold): Severe, sharp, localized joint pain aggravated by cold and relieved by warmth.
• Heavy / Damp Bi (Zhuo Bi - Dampness): Swollen, heavy, numb joints with localized fluid effusion.
• Febrile / Hot Bi (Re Bi - Heat): Joint is visibly red, swollen, hot to the touch, with excruciating burning pain.

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