By Nick Lampert

Case history

In order to illustrate some of the main principles of diagnosis and treatment in Chinese herbal medicine, I have chosen a case of chronic fatigue. This has become a familiar condition in our society (I don’t know how it stands in other societies). Chronic fatigue appears in different forms. Frequently, especially in young people, it is in the wake of an infectious disease (say glandular fever) after which a person cannot break back through to normal energy levels, and in the course of constantly struggling with the pathogen, whatever that pathogen is, energy levels continue to be depleted. In somewhat older people, a frequent underlying theme is a background period of intense commitment to success, which a person then can no longer sustain, because in some way their energies have been eroded by their life situation. This could be described as a state of strong inner conflict resulting from the sense, not necessarily conscious, that ‘there must be more to life than this’.

taking a pulseThe following case is an extreme one, but because it concerns a relatively young man, and one whose underlying constitution was strong, the prognosis was good and a lot could be achieved quickly. In other cases, one might need to think in terms of much longer treatment.

Patient: Male, 33

Brief history: Loss of energy over a 5-year period, background of many years of incredibly hard work as a marine engineer (18 hours a day), without break; suffered collapse 6 months before he came to see me, was hospitalised and diagnosed with ‘inflammation of central nervous system in the brain’ (whatever that might be), though other doctors disagreed and finding a conventional diagnosis remained problematic; there was no visible history of infection and 15,000 (sic) blood tests (including 5000 for tropical diseases) revealed nothing!

Signs & Symptoms

These were numerous. I shall group them into sections, which will make it easier to explain later the nature of the Chinese medicine diagnosis:

  1. Extreme fatigue
  2. Very nauseous, occasional vomiting; severe muscle fatigue and pain; poor concentration; heavy sleep, 11 hours, feels heavy in mornings; digestion not bad, but sometimes bloated, and appetite not great.
  3. Palpitations, can happen any time of day, come ‘down the body to the toes’; black spots in front of eyes; irritable
  4. Easily short of breath; sinus congestion has come on over the 5-year period
  5. Sometimes low-grade flu-like feelings; dry mouth
  6. Very frequent urination, every 30 minutes during day, 3 times at night
  7. Tongue: broad, red, darker edges, hint of a yellow coat
  8. Pulse: soft/thready, Kidney position very low

Medication: none at present (came off ibuprofen 2 months ago)

Chinese medicine diagnosis

Background principles

In the very broadest terms, Chinese medicine is always concerned either to improve energy levels, or to ensure that a person’s energy is flowing freely. ‘Energy’ is an inadequate translation of various aspects of energy, called Qi, Yang, Blood and Yin. The Qi is the dynamic principle, the Qi of any Organ must be abundant for it to function well and for any process of transformation (which is a condition of life) to occur. Blood refers to the fluid, nutritive aspect of energy which is, if you will, the fuel from which the Qi is derived. Qi belongs to Yang, Blood to Yin. If we represent life as a burning candle, then the flame is the Yang, the wax (the fuel) is the Yin. They are mutually dependent so that if the fuel is dry there can be no flame, while if there is no flame the fuel cannot continue to be created.

Energy can be reduced through over consumption of Qi/Yang or Blood/Yin, or it can be depleted if there is any sort of blockage which prevents the movement of Qi from occurring normally, which may affect any or several of the Organs. If someone is intensely committed to a particular type of work but is in a state of inner conflict over it, they will over consume Qi (this is more a matter of state of mind than sheer quantity of work, though of course there are limits to how much you can do however harmonious may be your relationship to your work). If Qi is over consumed, the person will have to draw on reserve energy, and if this goes on for long enough, the Blood/Yin aspect will be compromised.

If the Qi is depleted, a person will be susceptible to invasion by pathogenic factors, and because the Qi is depleted the pathogenic factors may linger without the power to throw them off. This further compromises the Qi dynamic so you are in a vicious circle. In this scenario, a very common outcome is that Dampness accumulates. Dampness is a very general term in Chinese medicine which points to an accumulation of fluids associated with poor digestion in the broadest sense, in turn associated with poor functioning of the Spleen (which is the central Organ of digestion). Accumulation of Dampness is also very often accompanied by excessive Heat, and the combination of Damp and Heat produce a specific set of symptoms.

Chinese medicine diagnosis:

Retention of Dampness (with some Damp-Heat) with deficiency of Qi (Spleen, Lung, Kidney) and depletion of Yin

The reasoning behind the diagnosis:

This patient had been obsessively hard-working for a number of years and could not continue in that vein without hitting a crisis. Looking at the groups of symptoms above, they can be interpreted in the following way in Chinese medicine terms:

(a) and (b): these symptoms point to a severe depletion of Qi (the exhaustion) and an accumulation of Dampness: when Damp affects the Stomach there is nausea, when it affects the muscles there is muscle fatigue and pain. It also tends to cloud the mind, hence in chronic fatigue syndromes poor concentration is a very frequent complaint. Sleep may become very heavy and the person is not refreshed in the mornings; typically the appetite is reduced and there is some form of digestive blockage like abdominal bloating.

(c) Depletion of energy can affect any Organ. Palpitations suggest that the Heart energy is affected, this occurs in particular if the Blood aspect of the Heart is involved. If the Blood of the Liver is depleted, visual symptoms (like black spots in front of the eyes) can occur, and can also lead to irritability because the Liver is especially responsible for maintaining a harmonious emotional state.

(d) Being easily short of breath means that the Qi of the Lungs has been compromised, while sinus congestion also points to damaged Lung function leading to accumulation of Phlegm.

(e) The recurrent low-grade flu-like feelings and dry mouth suggest the continued presence of Heat alongside the Dampness, though if the Heat was a major feature there would be more marked signs of it.

(f) Very frequent urination is a symptom of depleted Kidney energy, which is regarded as the grounding for the body-mind energy as a whole. If urinary symptoms start to appear in a young person under the circumstances of this case, it is a strong indication that remedial measures are urgently required.

(g) a red tongue with some yellow coat can be seen as a sign of the presence of Damp-Heat; in this context, it could also point to the development of Yin deficiency and internal heat from that source (like an engine with insufficient lubrication). It is not uncommon to find complex combinations of Dampness, which in a sense is an over accumulation of fluids, and Yin deficiency which indicates a depletion of the fluid/nourishing aspect.

(h) The pulse is a form of weak pulse which is hardly a surprise, and the Kidney position in particular is very low, confirming that the underlying reserves are threatened.

Treatment principle: to transform and
drain Damp, support Qi and nourish Yin

(Dosage in grams is given after each herb, the formula to be taken in decoction over two days, amounting to about 70 grams a day)

(1) The first prescription comprised herbs to:Tonify Qi: Huang qi 20, Ren shen 12, Bai Zhu 12, Zhi Gan cao 6 Resolve and transform Damp: Fu ling 12, Huo xiang 10, Sharen 12, Shi chang pu 10 Transform Phlegm: Ban xia 12, Chen pi 10 Clear Heat and raise the Yang: Sheng ma 10 Nourish Yin: Mai men dong 12

Response after 2 weeks: less tired, slightly less nausea, less irritable, far fewer palpitations, less sinus congestion, no flu-like feelings, less dry mouth. Developed some epigastric discomfort and acidity since taking the herbs, also became constipated with slight abdominal pain.


(2) I continued the same approach, modifying the formula to deal with constipation and other digestive symptoms. It now comprised herbs to:

Tonify Qi: Huang qi 20, Ren shen 12, Zhi gan cao 6, Bai zhu 12
Resolve and transform Damp: Fu ling 10, Huo xiang 10, Shi chang pu 10
Transform Phlegm: Ban xia 12, Chen pi 10 Alleviate epigastric symptoms: Huang lian 6, Wu zhu yu 4
Nourish Yin: Mai men dong 12 Alleviate constipation: Huo ma ren 15

Response after 2 weeks: Tiredness definitely more under control, lot less muscle fatigue, lot less nausea, less short of breath, no palpitations, no visual disturbances, motivation improved, no flu-like feelings, concentration improved though still not great, constipation and abdominal pain remain, little change in urination pattern


(3) The patient had made very good progress, which shows how quickly a Chinese herbal formula can help to ‘switch’ a person into a different mode. The outcome of the treatment thus far suggested that a major part in his case was played by the retention of pathogenic factors (in particular Dampness, but also Heat to some extent), and in someone whose underlying constitution is quite good, the effect of a treatment designed to clear pathogens can be dramatic. However, the urinary problem remained, which suggested that the Kidney (Yin and Yang) deficiency needed to be addressed more, so I next added more herbs for this, switching to a formula that was overall more tonifying with less emphasis on clearing pathogenic factors. Also, the digestive complications persisted. Digestive symptoms like bloating can be encouraged by certain herbs, and I suspected Huang qi, so I replaced that with Dang shen, and to deal with the abdominal pain added herbs to move and descend Qi.

Hence the next formula comprised herbs to:
Tonify Qi: Dang shen 15, Zhi gan cao 6 Resolve Damp/Phlegm: Ban xia 10, Chen pi 8 Transform Damp and regulate Qi: Hou po 12, Zhi shi 15
Nourish Blood and Yin: Dang gui 15, Bai shao 15, Mai men dong 15, Sheng di huang 12 Support Kidney Yang: Rou cong rong 15


Response:

4 weeks on this produced a very good result in most respects (energy levels, nausea, quality of sleep, concentration, mood, muscle aches); no change however in urination pattern. At this point I lost touch with the patient who was living far away, so I don’t know if the urinary symptoms cleared up later. It is very possible that, since his Spleen (day to day) energy had improved so much, the reserve energy of the Kidneys would eventually have been replenished and the urinary aspect would have got better as well, but this theory remains unproven!

About the Author

Nick Lampert. I started my work life as an academic in a field quite unrelated to Chinese medicine, enjoyed that for a number of years but then felt increasingly constrained by it. After a classic mid-life crisis, I broke away in pursuit of something where the benefits of my activities could be more directly felt. I studied acupuncture at the International College of Oriental Medicine (1989-90) and the London School of Acupuncture and Traditional Chinese Medicine (1990-92), and Chinese herbal medicine at the School of Chinese Herbal Medicine (1994-96) in London. I have been to China (Nanjing) twice on short clinical courses, first for additional acupuncture training in 1992 and then for further herbal training in 1996.

In 1995 I joined Margaret Ehrenberg and Charmian Wylde to set up the Birmingham Centre for Chinese Medicine, where I now work. I practice herbal medicine and acupuncture in about equal proportions.

Within the field of Chinese herbal medicine, I see mainly cases relating to skin disease, respiratory conditions, digestive disorders, chronic fatigue syndromes, and some gynaecological problems. All these are, in my experience, areas in which Chinese herbal medicine has a great deal to offer. In terms of the delivery of the herbs I am very much committed to traditional herbal teas, though to a limited extent I also use concentrated powders and prepared (patent) medicines in pill form.

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