This journal article originally appeared in The Lantern, Volume 13, No.3
Introduction
With all the new books being released every week, a number of international TCM journals at our hands, endless webinars and online seminars, I still find one basic deficiency in all the literature available for TCM practitioners That is, plain and simple detailed case histories of what practitioners did to treat a specific patient and ailment. What happened on a week to week basis? Why was the diagnosis chosen, what worked or what didn’t work? Were there aggravations and how long did the course of treatment take? Are we sure we had a long lasting result? I have presented some of my case histories at the annual Wellington Acupuncture New Zealand Conferences and I believe they were well received for their practicality and honesty and I hope this case history follows suit.
Background to case
I wanted to pick a complaint that is reasonably common and that can demonstrate the effectiveness of Chinese herbs. Also I aim to exemplify how not all patients will fit into a standard formula that is available as a patent.
Patient Male aged 24
He presented with a western medical diagnosis of post glandular fever syndrome. 9 months before coming for treatment he had a bout of severe sweating and fevers at night that lasted 3 days.
Since that first episode, each fortnight he would get reoccurring
- Aches and pains in the joints
- Eyes get sore
- Temple headaches
- Night sweats and fever
He went back to various doctors and all that could be told to him was that the blood test had confirmed Glandular Fever.
In addition to the above symptoms he also had ongoing
- Muscles-weak
- Glands- swollen
- Stomach- sore, worse with pressure
- Thirsty- constantly need sip water
- Appetite- low
- Brain fog- described as a cotton wool type feeing in head
- Chills and sweat with fever
- Ulcers on the inside lips
- Night talk (His partner commented that he now always chatted in his sleep)
- Bowels- loose
- Urine-dark
Examination of the pulse and tongue
- Pulse- slippery and slightly rapid
- Tongue- rear of tongue greasy and yellow, slightly thick with red spots on the edge of tongue body
The patient had become quite worn out since the first attack and was unable to keep up fulltime employment and struggled even with his cut back hours of less than 20 hours a week. His work involved sitting at a desk and doing concentrative type work.
The diagnosis according to TCM principles seemed quite straight forward as damp and heat with some key note symptoms standing out.
Important key note symptoms
- Lethargy
- Muscle weakness which is how he described it but our classic texts usually refer to this as heaviness in the body
- Loss in appetite
- Thirst (Desire to sip water usually indicates damp and heat as opposed to fire)
- Night sweats ( Note that night sweats are commonly also due to yin deficiency)
- Loose stools
- “Brain fog”- also referred to in other texts as “muzzy” head or difficult to concentrate
- Tongue- the rear of the body showing a greasy and yellow coat. Spots on outside in liver/gall bladder area ( A point of interest here is that I say spots and not “points” as they are just a little bit bigger than a pinhead size and not bright red but reddish- Giovanni Maciocia goes into this in-depth in his Tongue diagnosis book) )
Before I go into what I prescribed I would like to just comment that over the years I have seen a number of patients with similar presentations as above and I am sure many of you other practitioners also have. What is interesting is that many patients seek treatment outside of the western medical paradigm because it really does not have much offer. Unfortunately, in my experience, these patients seem to end up trying a naturopathic/western herbal type approach where they are prescribed herbs of a tonic nature because their chief symptom is tiredness.
This naturopathic treatment approach using Chinese herbs in glandular fever actually worsens the condition. For those ambitious tonic prescribing naturopaths I provide the quote “Thus the Wen Bing Tiao Bian (‘Systematic Differentiation of Warm Disease’, 1798) remarks: Moistening [this type of patient] will lead the disease to deepen without relief.’ “ – from Clavey Fluid Physiology and Pathology in Traditional Chinese Medicine p 440. The moistening in this quote refers to the wet moist greasy nature of yin tonics. If you prescribe thick cloying yin tonics to an existing damp or damp/heat condition, it will only worsen the damp.
One “Chinese herb” formula that the naturopaths in particular like to prescribe is Shi Quan Da Bu Wan All- Inclusive Great Tonifying Decoction. I am not sure why the marketers promoting the herbal pills picked this one out of the hat, but possibly because one of the ingredients, Huang Qi Astragali Radix has been shown to effect the immune system and the formula has the word “tonic” in the original name. The formula in New Zealand has been given exotic names like Astragulus Immuno Plus. If it is good for the immune system, it must be good for glandular fever, is I guess, their thinking.
From a traditional Chinese medicine perspective there are many formulae and variation of herbs that can treat all the different manifestations of damp and heat. In The Practice of Chinese Medicine by Giovanni Maciocia, the author lists a few formula that can be used to address the symptom of tiredness due to damp or Damp/Heat. These formula are Ping Wei San (Calm the Stomach Powder), Huo Xiang Zheng Qi Wan (Agastache Powder to rectify the Qi), Lian Po Yin (Coptis and Magnolia Bark Decoction) and Huo Po Xia Ling Tang (Agastache-Magnolia-Pinellia-Poria Combination).
However, for a more in-depth analysis of damp heat eliminating formulas, I suggest the extensive chapter of the topic in Clavey’s Fluid physiology and Pathology in TCM.
Readers may question why I didn’t prescribe herbs based more on these classical examples and that my prescriptions actually seem a bit like a whole bunch of herbs just thrown together. In order to explain this, I firstly need to outline where I obtained my Chinese herbal skills and experience. Before any major decent text on Chinese herbs in the English language was released I started working in Sydney’s Chinatown at the Chinese Ginseng and Herbs Company in 1985. In particular, Kevin Zheng Ping Lu, main resident herbalist and Phuoc Tran (Dr Chan the owner) took me under their wing and after fifteen or so years with them, I picked up a few things.
Mr Phuoc Tran third from left and Mr Kevin Zheng Ping Lu, third from right
Kevin Zheng Ping Lu who needs no introduction, is someone who knows all the Chinese herbal formula off by heart. He has seen more patients for Chinese herb consultations in Sydney than anyone else there. What is interesting though, is that he rarely uses a typical formula as a standalone, even with modifications. He uses as he says, bits and pieces from formulas as required. It is the additions and subtractions that make all the difference to counteract possible aggravations and adverse results or target a specific symptom. Dr Chan, on the other hand, has an incredible knowledge of couplet and triplet combinations and I have never ever seen him use even a part of a formula. Yet his combinations are incredibly simple and don’t contain very many herbs, yet they are powerfully effective. So with that, I present the initial prescription for the diagnosis of damp and heat or if you wanted to be a little bit more concise, Liver and Gall bladder damp and heat.
The first prescription consisted of one week supply of the below formula. The formula is written as if prescribing raw crude herbs but I actually dispensed the formula using Sun-Ten freeze dried granules. The herbs were to be taken twice a day.
- Shan Zhi Zi 9 grams Gardenia Fructus
- Dan Dou Chi 9 grams Sojae Semen Preparatum
- Dan Shen 6 grams Salvia Miltiorrhizae Radix
- Huang Lian 1 gram Coptidis Rhizoma
- Ze Xie 6 grams Alismatis Rhizoma
- Di Gu Pi 9 grams Lycii Cortex
- Sheng Jiang 3 slices Zingiberis Rhizome Recens
- Lu Gen 9 grams Phragmitis Rhizoma
- Jin Yin Hua 9 grams Lonicerae Flos
- Lai Fu Zi 6 grams Raphanin Semen
- Gan Cao 3 grams Glycyrrhizae Radix
Analysis of formula
Firstly you may notice the relatively conservative doses of herbs. Every case is different but I generally tend to prescribe quite modestly the first few sessions as a caution in case patients are sensitive or haven’t told me all their details. I would rather have no result as opposed to an aggravation. The first two herbs are the formula Zhi Zi Chi Tang (Gardenia and Prepared Soybean Decoction). This combination was selected here to vent out residual heat trapped in upper jiao. Dan Shen Salvia Miltiorrhizae Radix was used to clear heat as was Di Gu Pi Lycii Cortex. Di Gu Pi Lycii Cortex would more commonly be used to clear heat associated with yin deficiency but here I thought the yin had likely been damaged from the history of long term sweating. Huang Lian Coptidis Rhizoma to clear heat as evidenced by the dark urine. Ze xie Alismatis Rhizoma was used to work with Huang Lian Coptidis Rhizoma to clear heat through the urine. Lu Gen Phragmitis Rhizoma is cooling, promotes urination and “is not greasy in nature, and does not have the effect of retaining pathogens within the body” Page 107 Chinese herbal Medicine Materia Medica 3rd edition Bensky, Clavey and Stoger. Jin Yin Hua Lonicerae Flos clears heat and resolves toxins but “while it is not emphasized nowadays, this herb also tonifies deficiency, enriches the blood, and alleviates thirst” Page 149 Chinese herbal Medicine Materia Medica 3rd edition Bensky, Clavey and Stoger. Gan Cao Glycyrrhizae Radix and Lai Fu Zi Raphanin Semen were added to help the spleen and protect against possible excess cooling nature of other herbs.
Second visit (1 week later)
He was still having night sweats but his bowels had become normal. He said his muscles felt stronger and as if his “shield” was up protecting him from getting colds and flu. The appetite was back to normal and there were no more chills and fever. The most surprising change for me however was the tongue.
The red spots on the tongue had disappeared along with the coating at the back.
My experience is that long term chronic damp heat doesn’t change overnight, so after just a week to see the tongue clear of damp heat was a surprise. I prescribed a repeat of the previous prescription with the deletion of Huang Lian Coptidis Rhizoma and addition of Lian Qiao Forsythia Fructus. Huang Lian Coptidis Rhizoma was omitted because being so cold and bitter I didn’t want to prescribe it unless I absolutely had to and used Lian Qiao Forsythia Fructus instead to continue the cooling process.
- Shan zhi zi 9 grams Gardenia Fructus
- Dan Dou Chi 6 grams Sojae Semen Preparatum
- Dan Shen 6 grams Salvia Miltiorrhizae Radix
- Ze Xie 5 grams Alismatis Rhizoma
- Di Gu Pi 6 grams Lycii Cortex
- Sheng Jiang 3 slices Zingiberis Rhizome Recens
- Gan Cao 3 grams Glycyrrhizae Radix
- Lu Gen 6 grams Phragmitis Rhizoma
- Lian Qiao 5 grams Forsythia Fructus
- Jin Yin Hua 6 grams Lonicerae Flos
- (2 weeks supply)
Third visit (3 weeks later)
He caught a cold but got over it very quickly. No night sweats, muscles normal, thirst and appetite normal, brain fog improving. By this stage he had returned to work full time.
Same formula as above but minus Lu Gen Phragmitis Rhizoma and added Zhu Ru Bambusae Caulis in taeniam (Two weeks supply)
I can’t say why there was any particular reason I substituted Lu Gen Phragmitis Rhizomawith Zhu Ru Bambusae Caulis in taeniam. I may just have run out of Lu Gen Phragmitis Rhizoma!
Fourth visit (3 weeks later)
Herbs as above with addition of Ye Jiao Teng 12 grams Polygoni Multiflora Caulis (2 weeks supply)
This time he remarked that he had not been sleeping as well so I used Ye Jiao Teng Polygoni Multiflora to help his sleep.
Fifth visit (6 weeks later)
By this stage he remarked that he was feeling like his old self and just wanted some herbs to keep him well. Even though there were no damp heat signs present I was still hesitant to prescribe “tonics” in case they would aggravate any hidden pathogenic damp. The proof would be in the pudding I thought, and I prescribed 2 weeks of herbs including Dang Shen Codonopis Radix and Bai Zhu Atractylodis macrocephalae Rhizoma which are warming tonics. The addition of Yu Xing Cao Houttunaie Herba was as a safe guard to urinate out any excess heat from the tonics.
- Shi Chang Pu Acori tatarinowaii Rhizoma was used to treat damp and fortify the spleen.
- Dang Shen 9 grams Codonopis Radix
- Bai Zhu 6 grams Atractylodis macrocephalae Rhizoma
- Fu Ling 9 grams Poria
- Gan Cao 3 grams Glycyrrhizae Radix
- Zhu Ru 9 grams Bambusae Caulis in taeniam
- Jin Yin Hua 9 grams Lonicerae Flos
- Lu Gen 9 grams Phragmitis Rhizoma
- Ze Xie 9 grams Alismatis Rhizoma
- Yu Xing Cao 6 grams Houttunaie Herba
- Shi Chang Pu 6 grams Acori tatarinowaii Rhizoma
- (2 weeks supply)
Sixth visit (2 months later)
He had been good up until this week when he started sweating at night again, and was tired during week at work and noticed a slight body ache returning. Did I start on the tonics too soon or unnecessarily? Or is that just the nature of latent pathogens? On the hand I know it is wise to be careful over prescribing cooling herbs in case they damage the stomach and spleen.
A self-criticism here is required here as I didn’t record what I prescribed!
Seventh visit (2 months later)
In the past week there had been a relapse with sudden tiredness, he had caught a few colds, been having some headaches and the night sweats had returned. These latent pathogens were lurking havoc again!
- Dan Dou Chi 9 grams Sojae Semen Preparatum
- Shan Zhi Zi 9 grams Gardenia Fructus
- Zhu Ru 9 grams Bambusae Caulis in taeniam
- Gan Cao 6 grams Glycyrrhizae Radix
- Ge Gen 12 grams Puerariae Radix
- Chuan Xiong 6 grams Chuanxiong Rhizoma
- Man Jing Zi 6 grams Viticus Fructus
- Dang Shen 9 grams Codonopis Radix
I think this prescription is self-explanatory. Ge Gen Puerariae Radix, Chuan Xiong Chuanxiong Rhizoma and Man Jing Zi Viticus Fructus to treat the headache.
(2 weeks supply)
He came back again six months later with some acute throat ulcers.
He came back again 4 months later with tiredness and swollen glands in the neck. Both times 2 weeks’ worth of herbs were prescribed.
Conclusions and lessons learnt
At the time of writing it has been 4 months since I have seen him. I suspect he will come back again. Some practitioners could suggest that I see him more regularly to get a better longer lasting result. I am left with two choices. If I kept prescribing cooling herbs along the lines of previous treatment strategies, it is feasible that their longer term use could damage stomach and spleen energy, Could prescribing tonics, even gentle ones like Dang Shen Codonopis Radix or Tai Zi Shen Pseudostellariae Radix just provide fuel to feed the hidden pathogen. The patient has experienced better health since starting treatment so I will take it as a sign to keep doing what I am doing.
