The disease category of chronic fatigue syndrome (also called chronic fatigue immune deficiency syndrome or CFIDS) has only recently entered the Chinese medical literature, where it has begun, in a number of patients, to replace the previously popular disease category of neurasthenia (shen jing shuai rou).
In the November 2000 issue of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), there is an interesting article titled "Self-Composed Bu Gan Yi Qi Tang (supplement the liver & boost the qi decoction) in the Treatment of 46 Cases of Chronic Fatigue Syndrome" by Zhu Guang-wen.1 A summary of what I find to be the salient features of that article is given below.
Cohort Description
Among the 46 patients in this study, 31 were male and 15 were female. These patients ranged in age from 19-44. Their clinical symptoms included a long period of extreme fatigue; a wan effect; emotional depression; insomnia; impaired memory; occasional sighing; scanty qi and a disinclination to talk or faint voice; no thought for food and drink or indigestion; flabby muscles; lack of strength; possible muscle-joint soreness and pain; heart palpitations; shortness of breath; and an inability to recuperate. After various sorts of examination, organic disease had been ruled out.
Treatment Method
Self-composed bu gan yi qi tang consisted of 30g each of radix astragali membranacei (huang qi); herba agrimoniae pilosae (xian he cao); and bulbus lilii (bai he); 10g each of radix rubrus panacis ginseng (hong shen); fructus corni officinalis (shan zhu yu); radix bupleuri (chai hu); fructus citri aurantii (zhi ke); pericarpium citri reticulatae (chen pi); and radix angelicae sinensis (dang gui); and 12g each of rhizoma actractylodis macrocephalae (bai zhu) and radix albus paeoniae lactiflorae (bai shao). If there was a tendency toward heat, rhizoma coptidis chinensis (huang lian) and radix scutellariae baicalensis (huang qin) were added. If there was yang vacuity, herba epimedii (xian ling pi) and rhizoma curculiginis orchiodis (xian mao) were added. If there was torpid intake, massa medica fermentata (shen qu), fructus crataegi (shan zha) and fructus germinatus horedi vulgaris (mai ya) were added. If there was insomnia and heart palpitations, radix sophorae flavescentis (ku shen) and stir-fried semen zizyphi spinosae (suan zao ren) were added. Ten ji equaled one course of treatment. Treatment consisted of 1-3 courses.
Treatment Outcomes
Thirty-five (76.09%) out of 46 patients were judged cured, which meant that their symptoms completely disappeared. Eleven patients (23.91%) improved, meaning that their clinical symptoms lessened. Thus, the total effectiveness rate was 100% using this protocol.
Discussion
In his discussion, Zhu Guang-wen presents an argument for the diagnosis of liver qi vacuity as the main Chinese medical disease mechanism of this disease. Personally, I find Zhu's use of this pattern an unnecessary terminological obfuscation. In my reading of the Chinese medical literature, the overwhelming majority of Chinese medical textbooks on pattern discrimination do not even mention a liver qi vacuity pattern. Because it is a statement of fact in Chinese medicine that "the liver commonly has a surplus," typically, the term "liver qi" is used as a contraction for liver depression qi stagnation. If one looks at the above formula as well as the patients' signs and symptoms, it is clear that they suffered from a liver-spleen disharmony. This means a combination of liver depression and spleen vacuity. Spleen vacuity symptoms included fatigue; lack of strength; disinclination to speak or faint, weak voice; shortness of breath; no thought for eating or drinking, or indigestion (after meals); and flabby, atonic muscles and flesh. The symptoms of liver depression were emotional depression and periodic sighing. Because the spleen is the latter heaven root of qi and blood engenderment and transformation, spleen vacuity has led to a heart qi and blood vacuity as evidenced by symptoms of heart spirit nonconstruction and malnourishment, including insomnia and impaired memory. Liver blood vacuity resulted in muscle-joint soreness and pain due to malnourishment of the sinews.2
This reading of the signs and symptoms given by Zhu as characteristic of his chronic fatigue patients is borne out by an analysis of his formula. Huang qi, xian he cao, hong shen and bai zhu all supplment the spleen and boost the qi. Contemporary Chinese materia medica, such as Bensky and Gamble's Chinese Herbal Medicine: Materia Medica, do not list any Chinese medicinals that specifically supplement the liver qi. Together, chai hu, zhi ke and chen pi course the liver and rectify the qi. Dang gui and bai shao supplement the blood, thus nourishing the heart spirit above and harmonizing and emolliating the liver below. Bai he nourishes heart blood and yin and thus quiets the spirit. Shan zhu yu is an astringing medicinal, but it also supplements liver blood and kidney qi. Hence, it is sometimes also said to fill the essence and invigorate yang. Since the former and latter heavens are mutually rooted, its inclusion in this formula helps make the formula more harmonious and holistic.
Virtually all the patients with CFIDS I have treated over the last 20 years have had a liver-spleen disharmony sitting squarely in the middle of their Chinese disease mechanisms. As Zhu's protocol shows via its various additions, this central disease mechanism may then be complicated by any of a number of other related disease mechanisms. Zhu lists (depressive or damp) heat, food stagnation and yang vacuity as commonly seen complications. From my own clinical experience, I would add phlegm dampness, yin vacuity, vacuity heat and blood stasis, and other commonly seen complications. Because there is often a defensive qi vacuity ultimately due to spleen vacuity, there may also be lingering external evils in the exterior, or deep-lying evils in the blood aspect or division.
If there is concomitant dampness, I would add sclerotium poriae cocos (fu ling) and rhizoma pinelliae ternatae (ban xia), at least as a being, to Zhu's formula. If there is yin vacuity, I would probably choose between fructus lycii chinensis (gou qi zi), fructus ligustri lucidi (nu zhen zi), fructus schisandrae chinensis (wu wei zi), cooked radix rehmanniae (shu di) and processed radix polygoni multiflori (he shou wu). If there is vacuity heat, I would probably add rhizoma anemarrhenae aspheloidis (zhi mu) and cortex phellodendri (huang bai). If there is blood stasis, I might choose between radix rubrus paeoniae lactiflorae (chi shao), radix salviae miltiorrhizae (dan shen), cortex radicis moutan (dan pi) or herba leonuri heterophylli (yi mu cao). If there were lingering wind evils in the exterior, I would probably first think of adding radix ledebouriellae divaricatae (fang feng), while for warm evils hidden or deeply lying in the blood, I would probably consider radix lithospermi seu arnebiae (zi cao), flos lonicerae japonicae (jin yin hua), fructus forsythiae suspensae (lian qiao), herba taraxaci mongolici cum radice (pu gong ying) and/or radix isatidis seu baphicancanthi (ban lan gen).
In closing, I would like to comment on the fact that I find two medicinals chosen by Zhu quite interesting in the context of CFIDS. They are bai he and xian he cao. Bai he is Zhang Zhong-jing's flagship medicinal for lily disease. The symptoms of lily disease are a restless or disquieted spirit; taciturnity and little speech; a desire (but inability) to eat; a desire (but inability) to move; a desire to sleep but inability to eat; and a tendency to vomit up Chinese medicinals that otherwise appear appropriate for the patterns at hand. Patients with lily disease appear to have a normal body and do not look obviously diseased. Bai he is one of the spirit-quieting medicinals favored by the gu worm school of Chinese medicine, and many patients with CFIDS have been told by other practitioners that they have intestinal dysbiosis, candidasis, parasites or leaky guy syndrome. Along these same lines, it is interesting to note that xian he cao also kills worms or parasites at the same time it stops diarrhea.3 At least four other medicinals in this formula were favored by gu worm practitioners: chai hu, dang gui, bai shao and chen pi. According to Heiner Fruehauf, gu worm conditions are characterized by a combination of mental-emotional disorders, musculoskeletal disorders (e.g., chronic soreness and pain and wilting) and digestive disorders4 -- just the sort of combination of symptoms Zhu describes in his article on chronic fatigue syndrome.
References
- Zhu Guang-wen. Self-composed bu gan yi qi tang in the treatment of 46 cases of chronic fatigue syndrome. Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine) 2000;11:476.
- I have seen one other article on liver qi vacuity in the Chinese medical journal literature. In that case as well, the signs and symptoms of liver qi vacuity were really only a combination of liver depression plus spleen vacuity.
- Here we are talking about the Chinese medical concept of worms or parasites (chong), not their Western medical counterpart.
- Fruehauf H. Driving out demons and snakes: gu syndrome and a forgotten clinical approach to chronic parasitism. Journal of Chinese Medicine 1998;5:10-17.
Click here for previous articles by Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK).