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Chronic fatigue syndrome (CFS) is an increasingly common diagnosis in China, as evidenced by the regularly appearing articles on its treatment in Chinese medical journals. Below are summaries of three recently published Chinese articles on the treatment of CFS with Chinese herbal medicine.

Article 1
On page 65 of issue #4, 2007 of the Shi Yong Zhong Yi Nei Ke Za Zhi (Journal of Practical Chinese Medicine Internal Medicine), Zhuo Li-yong published "The Treatment of 94 Cases of Chronic Fatigue Syndrome with Liu Wei Di Huang Wan with Additions & Subtractions."

Cohort Description
Altogether, there were 190 cases of CFS enrolled in this study. All of these cases met both Chinese and American diagnostic criteria for this condition. These 190 cases were then randomly divided into a treatment group of 94 and a comparison group of 96. In the treatment group, there were 39 males and 55 females, 17-58 years of age, with an average age of 37 years. These patients had suffered from CFS for from eight months to 15 years, with an average disease duration of five years. In the comparison group, there were 42 males and 54 females, 18-60 years of age, with an average age of 35. These patients had suffered from CFS from six months to 14 years, with an average disease duration of 5.5 years. Thus these two groups were considered statistically comparable for the purposes of this study in terms of sex, age, and disease duration.

Treatment Method
All members of the treatment group were orally administered the following modified version of Liu Wei Di Huang Wan:

• Shu Di Huang (cooked Radix Rehmanniae), 15g
• Shan Yao (Radix Dioscoreae), 24g
• Fu Ling (Poria), 12g
• uncooked Huang Qi (Radix Astragali), 24g
• Xian He Cao (Herba Agrimoniae), 30g
• Shan Zhu Yu (Fructus Corni), 10g
• Ze Xie (Rhizoma Alismatis), 12g
• Yin Yang Huo (Herba Epimedii), 15g
• Tu Si Zi (Semen Cuscutae), 24g
• Shi Hu (Herba Dendrobii), 15g
• Da Zao (Fructus Jujubae), 7 pieces

If there was marked qi vacuity, 15 grams of Xi Yang Shen (Radix Panacis Quinquefolii) were added. If there was marked yin vacuity, 15 grams of mix-fried Gui Ban (Plastrum Testudinis) were added.

One packet of these medicinals was decocted in water down to 300 milliliters of medicinal liquid and administered in divided doses morning and evenings 30 minutes after eating. Four continuous weeks of this treatment equaled one course of treatment.

All members of the comparison group were administered the Chinese ready-made medicine Xiao Pi Ling Ke Li (Disperse Exhaustion Magically Effective Pillules, manufactured by the Zhejiang Great Virtue Pharmaceutical Company). Ten grams of these pills were administered each time, three times per day after meals. Treatment lasted four weeks. During the course of treatment, all members of both groups stopped taking any other medications and regulated their lifestyles. Treatment outcomes were analyzed for both groups after one course of treatment.

Study Outcomes
Cure was defined as complete disappearance of fatigue with no recurrence on follow-up after six months. Marked effect was defined as complete disappearance of fatigue but some recurrence on follow-up after six months. Some effect meant that the fatigue was markedly less and that there were occasional recurrences on follow-up after six months. No effect meant that there was no obvious change in the patient's condition from before to after treatment. Table 1 shows the outcomes of the two groups based on these criteria.

Table 1: Study 1 Outcomes

Discussion
The etiology of CFS is presently unknown. However, research has shown that its onset is somehow related to lifestyle and psychology. According to Dr. Zhuo, CFS corresponds to the traditional Chinese disease category of vacuity taxation. According to Chinese medical theory, the kidneys are the former heaven root and govern the storage of essence. Essence, qi, and spirit are the material bases of the human body. If essence, qi, and spirit tend to be vacuous, then any of hundreds of diseases may arise. If thought and worry are excessive, they may consume and exhaust the heart and spleen. Because the heart is the child of the liver, worry may also eventually damage the liver, and the liver and kidneys share a common source. Hence yin and blood are internally consumed, and kidney yin also become vacuous. This can lead to lassitude of the spirit and lack of strength, dizziness and vertigo, insomnia, impaired memory, low back and knee soreness and limpness, low-grade fever, and sore throat, all typical symptoms of liver-kidney yin vacuity. In this case, the disease mechanism mostly is viscera and bowel depletion and vacuity with essence, qi, and spirit insufficiency. Liu Wei Di Huang Wan originated in the Tang dynasty, and its functions are to enrich and supplement the liver and kidneys. Within this formula, Shu Di enriches kidney yin and boosts the essence and marrow. Shan Yao enriches the kidneys and supplements the spleen. Shan Zhu Yu enriches the kidneys and boosts the liver. Xian He Cao, when combined with Da Zao, boosts the qi and supplements vacuity, disperses and eliminates fatigue and taxation. Ren Shen (Radix Ginseng) [sic] and Yin Yang Huo are both effective for fatigue taxation and are even more effective for this purpose when prescribed together. Huang Qi is an extremely important qi-supplementing medicinal. It is able to boost the qi and rectify the blood. It also promotes a human's disordered bodily qi and blood to obtain balance. In particular, it is able to eliminate the symptom of fatigue. Thus, this formula restores the evenness and harmony of the entire body's yin and yang as well as fortifies or brings back to health the function of all the viscera and bowels. Hence, it achieves relatively good therapeutic effects in the treatment of this condition.

Article 2
On pages 394-395 of issue #7, 2007 of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), Shi Xue-ying published "The Therapeutic Effects of Treating Liver Depression-Spleen Vacuity Pattern Chronic Fatigue Syndrome with Xiao Yao San (Rambling Powder) in Patients with Immune Function Disturbance."

Cohort Description
Forty-six patients meeting the US Centers for Disease Control (CDC) criteria for CFS were enrolled in this cohort study. Among these 46, there were 14 males and 32 females, aged 18-65 years. Eight of these cases were under 30 years of age, 16 were 31-40, 11 were 41-50, and 11 were over 50 years old. Twenty cases had suffered from CFS for six months to two years, and 26 patients had suffered from CFS for more than two years. These patients made up the treatment group, and they were compared to a healthy group of 25 persons who were statistically comparable in terms of age and sex.

Treatment Method
All patients in the treatment group were administered the following version of Xiao Yao San:

• Chai Hu (Radix Bupleuri)
• Dang Gui (Radix Angelicae Sinensis)
• Bai Shao (Radix Alba Paeoniae)
• scorched Bai Zhu (Rhizoma Atractylodis Macrocephalae)
• Fu Ling (Poriae), 10g each
• mix-fried Gan Cao (Radix Glycyrrhizae), 6g
• Sheng Jiang (uncooked Rhizoma Zingiberis)
• Bo He (Herba Menthae Haplocalycis), 5g each

One packet of these medicinals was decocted in water two times and administered orally in divided doses morning and evening. This treatment was given continuously for two months. During that time, patients stopped taking any other Chinese or Western medicines. The severity of patients' clinical signs and symptoms were assessed before and after treatment. Natural killer (NK) cells in the blood were measured before and after treatment as well as IgA, IgG, and IgM.

Study Outcomes
Table 2 shows the differences of severity of the symptoms of CFS in the treatment group from before to after treatment.

Table 2: Severity of Symptoms Pre- and Post-Treatment

In all cases, there was a significant reduction in the overall severity of the above symptoms from before to after treatment. Except for poor appetite in one case, none of these patients suffered from severe symptoms after treatment. By assigning a point system to the severity of the above symptoms, the median points before treatment were 42.06 ± 8.25, while the median points after treatment were only 18.23 ± 6.18. Similarly, using this same point system, nine cases were judged clinically cured, 31 cases experienced a marked effect, three cases experienced some effect, and three cases experienced no effect, for a total effectiveness rate of 87%.

Table 3 shows mean serum NK cell numbers and IgA, IgG, and IgM in both the healthy comparison group and the treatment group before and after treatment.

Table 3: Results in Healthy Comparison Group and Treatment Group

As the reader can see, mean serum NK cells in the treatment group were low compared to the healthy group and markedly increased after treatment to just slightly less than the normal healthy group. IgA, IgG, and IgM were also all low in the treatment group and also all increased significantly after treatment, although remaining less than the normal healthy group.

Discussion
According to Dr. Shi, loss of regulation between the liver and spleen is the main pattern he sees in patients with CFS. Therefore, he commonly treats this condition with Xiao Yao San (Rambling Powder). Within this formula, Chai Hu courses the liver and resolves depression, while Dang Gui and Bai Shao nourish the blood and emolliate the liver. Bai Zhu, Fu Ling, and Sheng Jiang fortify the spleen and stomach and strengthen movement and transformation. Bo He assists coursing, scattering, spreading, and extending. Gan Cao boosts the qi and harmonizes the center. Hence, when these medicinals are used together, they have the effect of coursing the liver and resolving depression, fortifying the spleen and harmonizing the constructive. As this research shows, patients with CFS have a hypofunctional immune system, and treating their presenting pattern with Chinese medicinals improves immune function as measured by NK cells and immunoglobulins.

Article 3
On page 94 of issue #6, 2007 of Xin Zhong Yi (New Chinese Medicine), Wang Qiu-ping published "The Treatment of Chronic Fatigue Syndrome Via Three Steps Based on Knowledge Gained from Experience." In this article, Dr. Wang outlines a three-step treatment protocol for this condition.

1. Level the liver and extinguish wind; quickly treat the tips [or branches].
Dr. Wang's first step of treating patients with CFS is based on his experience that these patients commonly present with dizziness, headache, sore neck, heart palpitations and fearful throbbing, vexation, agitation, restlessness, insomnia, profuse dreams, a dry mouth with a bitter taste, thin, yellow tongue fur, and a vacuous, agitated pulse. These symptoms correspond to a pattern of ascendant liver yang hyperactivity with internal wind harassing above. The liver's main physiologic functions are its governance of the storage of blood and its governance over coursing and discharge. Its body is yin, but its function is yang. The liver is categorized as wood in terms of the five phases. Therefore, it governs stirring and upbearing. It is the liver's ability to store the blood that controls and restrains ascendant liver yang hyperactivity. The nature of CFS is that it is a long-term condition that exhausts and consumes the body's yin and blood internally. As Wang Bing said,

The liver stores the blood, [while] the heart moves it. Stirring leads to
the blood's movement within all the channels. [However, when] a person
[is] still, this leads to blood returning to the liver viscus.

If liver blood is consumed internally, it is not able to control and restrain liver yang. Yin is vacuous, and yang becomes hyperactive. Thus, vacuity wind harasses the clear orifices above, leading to dizziness and headache. This harassment also stirs the heart spirit, which leads to heart palpitations and fearful throbbing, vexation, agitation, and restlessness. The liver stores the ethereal soul, and the ethereal soul is nothing other than a manifestation of the spirit. Blood is the main material basis of both the spirit and the ethereal soul. Therefore, it is said, "The liver stores the blood [and] the blood is the abode of the ethereal soul." If liver blood is insufficient, the spirit has no abode in which to lodge. The clinical manifestations of this are susceptibility to fright, profuse dreams, and restless sleep. Agitation and stirring of wind and yang consume and damage fluids and humors, thus leading to a dry mouth with a bitter taste as well as thin, yellow tongue fur and a vacuous, agitated pulse.

Based on the above, Dr. Wang says that one first should level the liver and extinguish wind using the following formula:

• Sheng Di Huang (uncooked Radix Rehmanniae), 40g
• Ci Ji Li (Fructus Tribuli)
• uncooked Mai Ya (Fructus Germinatus Hordei)
• Yin Chen Hao (Herba Artemisiae Scopariae), 6g each
• Gou Teng (Ramulus Uncariae Cum Uncis)
• He Huan Pi (Cortex Albiziae)
• Yu Jin (Tuber Curcumae), 10g each
• Ye Jiao Teng (Caulis Polygoni Multiflori)
• Fu Shen (Sclerotium Pararadicis Poriae), 30g each
• Dang Shen (Radix Codonopsis)
• Shi Jue Ming (Concha Haliotidis)
• Dan Shen (Radix Salviae Miltiorrhizae), 15g each

Within this formula, a heavy dose of Sheng Di Huang enriches and nourishes the liver and kidneys, cools the blood and moistens dryness. Gou Teng levels the liver and extinguishes wind. It also has the function of settling and stilling. Shi Jue Ming levels the liver and subdues yang. Ci Ji Li courses the liver and dispels wind, levels the liver and regulates the liver qi. A small amount of Yin Chen Hao clears heat from the liver and gallbladder as well as rectifies liver-gallbladder depression. Hence, heat is dispersed, and depression is upborne. This is assisted by uncooked Mai Ya, which also effuses and upbears the qi. Its nature is to regulate the flow of the liver qi's spreading and extending. Ye Jiao Teng and He Huan Pi nourish the blood and resolve depression, quicken the blood and free the flow of the network vessels, quiet the spirit and stabilize the mind. Dang Shen fortifies the spleen and supplements the qi, while Fu Shen disinhibits water and seeps dampness, thus preventing the accumulation of dampness from producing phlegm. It also calms the heart and quiets the spirit. The use of these two medicinals is based on the saying, "[If] one sees liver disease, know that the liver transmits to the spleen [and] so one must first replete the spleen." Yu Jin and Dan Shen soothe and ease the flow of the qi mechanism, free the flow and out-thrust stasis and stagnation. Therefore, they free and ease the flow of both the qi and the blood.

2. Enrich and nourish the liver and kidneys, balance yin and yang.
After wind and yang have been leveled and extinguished, respectively, clinically one sees marked signs of liver-kidney insufficiency as the root of the disease. This is evidenced by unremitting fatigue accompanied by heart palpitations, insomnia, restlessness, and a fine, weak pulse. In this case, the pattern is categorized as liver-kidney essence depletion with blood not nourishing the spirit. If liver blood and kidney essence become insufficient, then the spirit suffers from lassitude and the body from lack of strength. In addition, there are heart palpitations and fearful throbbing. To treat this, Dr. Wang says one should supplement and boost the liver and kidneys and enrich, nourish, and quiet the spirit. The formula he suggests is Zuo Gui Yin (Restore the Left Beverage) and Sheng Mai Yin (Engender the Pulse Beverage) plus Suan Zao Ren Tang (Zizyphus Spinosa Decoction) with additions and subtractions:

• Suan Zao Ren (Semen Zizyphi Spinosae)
• He Huan Pi (Cortex Albiziae)
• Shan Zhu Yu (Fructus Corni)
• Tu Si Zi (Semen Cuscutae)
• Dang Shen (Radix Codonopsis)
• Mai Men Dong (Tuber Ophiopogonis), 10g each
• Fu Shen (Sclerotium Pararadicis Poriae)
• Ye Jiao Teng (Caulis Polygoni Multiflori)
• He Shou Wu (Radix Polygoni Multiflori), 30g each
• Sheng Di Huang (uncooked Radix Rehmanniae)
• Shu Di Huang (cooked Radix Rehmanniae)
• Dan Shen (Radix Salviae Miltiorrhizae), 15g each
• Gua Lou (Fructus Trichosanthis), 6g

Within this formula, Suan Zao Ren, Ye Jiao Teng, and He Huan Pi nourish the heart and boost the liver, quiet the spirit and stabilize the mind. He Shou Wu astringes the essence and secures the qi, supplements the liver and enriches the kidneys. Sheng Di Huang and Shu Di Huang enrich yin and supplement the kidneys, nourish the blood and boost the essence. Shan Zhu Yu supplements the liver, astringes the essence, and secretes the qi. Tu Si Zi boosts the three yin and strengthens the defensive qi. Dang Shen and Mai Men Dong boost the qi and nourish yin, nourish and clear the heart. Fu Shen, Dan Shen, and Gua Lou transform phlegm and dispel stasis, move the blood and quiet the spirit. When all these medicinals are used together, they supplement and boost the liver and kidneys, and enrich, nourish, and quiet the spirit. When the essence is engendered and the blood is sufficient, fatigue and lack of strength are improved and ameliorated.

3. Fortify the spleen and nourish the heart, improve and ameliorate the physical body.
According to the authors of the Su Wen (Simple Questions):

The spleen and stomach, large intestine, small intestine, three burners,
and the bladder are the root of the storehouse of endowment and the
abode of the constructive... They are of the category of utmost yin and communicate with the earth qi.

Earth is the origin of the tens of thousands of things. Thus, it is said, "The spleen is the latter heaven root." Liver blood and kidney essence both come from this source, and supplementing and filling the spleen qi enriches, engenders, and transforms this source. Therefore, if the spleen qi is fortified and moving, the finest essence of food and drink is full and sufficient. This then leads to the engenderment and transformation of the liver and kidney essence and blood having a source. This promotes and ameliorates the physical body and secures the therapeutic effects already gained. The formula Dr. Wang recommends for this purpose is Gui Pi Tang (Restore the Spleen Decoction) with additions and subtractions:

• Huang Qi (Radix Astragali)
• Dang Gui (Radix Angelicae Sinensis)
• Suan Zao Ren (Semen Zizyphi Spinosae)
• Yuan Zhi (Radix Polygalae)
• Mai Men Dong (Tuber Ophiopogonis)
• Mu Xiang (Radix Auklandiae)
• Dang Shen (Radix Codonopsis), 10g each
• Fu Shen (Sclerotium Pararadicis Poriae)
• Ye Jiao Teng (Caulis Polygoni Multiflori)
• Bai Shao (Radix Alba Paeoniae)
• Dan Shen (Radix Salviae Miltiorrhizae), 15g each
• Wu Wei Zi (Fructus Schisandrae)
• Gan Cao (Radix Glycyrrhizae), 3g each

Within this formula, Huang Qi, Dang Shen, and Gan Cao supplement the spleen and boost the qi. When the spleen qi is strong, it is able to engender and contain the blood. Fu Shen, Yuan Zhi, Suan Zao Ren, and Ye Jiao Teng supplement the heart and boost the spleen. When heart yin recovers, it is able to engender the blood and construct the spleen. Dang Gui and Dan Shen nourish the blood and construct the heart. Mu Xiang moves the qi and soothes the spleen. Mai Men Dong and Wu Wei Zi promote the boosting of the lungs and kidneys. Bai Shao restrains the liver and enriches the kidneys. When all these medicinals are used together, they promote the sufficiency of heart blood, the strength of the spleen qi, and fortification of both the mother and child. Hence, all the symptoms of fatigue and lassitude are eliminated.

In the representative case history Dr. Wang provides as an example of this approach, he prescribed formula No. 1 for one week. At the end of that week, the patient's heart palpitations and agitation had remitted. Then Dr. Wang prescribed formula No. 2 for 20 days based on the fact that the patient was still fatigued and had a sore neck and that these were worse after activity. After this, he prescribed formula No. 3 in order to regulate and rectify and generally improve the patient's condition. Although he does not say how long the patient took formula No. 3, he does say that this regime was very effective.

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