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Herbal approaches to pathological states

Apart from their use to provide non-specific support
for recuperation and repair, specific phytotherapeutic
strategies include the following.

Treatment of:
chronic fatigue syndrome;
fatigue and debility after illness, injury or trauma
Management of:
fatigue linked to clinical depression;
fatigue due to unbeatable or terminal illness.

Because of the use of secondarj~plant products, caution is necessary in applying phytotherapy in cases of:
severe digestive depletion;
renal or hepatic failure.

A debilitating symptom
Phytotherapists increasingly find that a major indication for treatment is a degenerative or debilitating illness. Unlike their forebears, for whom acute diseases
were the norm and recuperative support of debility
was usually convalescent aftercare, the modern practitioner will be less often involved in first-line treatment. Patients will more often report for help after
years of ill health or when conventional medicine has
run out of options.
There are many diseases that can lead to such signs
of debility as tiredness, inability to rest, weakness,
depression, wasting and anorexia. Indeed, any illness of
sufficient duration or severity can lead to such symptoms; chronic low-grade infections, especially viral
infections, are particular precursors in modern times. In
some cases severe or traumatic diseases from the distant
past can lead to a legacy of weaknesses of this type. A
few are constitutionally enfeebled and are prone to
debilitating responses to a range of stressors. A good
practitioner will obviously seek to address current problems as far as possible. However, one of the prominent
elements of a debilitating condition is that the weakness
imposes its own limitations on any treatment. It is often
impractical to embark upon the usual treatment strategy while the patient is at a lcw ebb as even the gentlest
remedies can provoke uncomfortable responses.
Finding a regime of treatment that simply addresses the debility, with little consideration of the causes
or background factors, might be the only strategy
feasible if the condition is especially severe. The


principles involved in such approaches can best

be reviewed for a classic modern svndrome of
debility - chronic fatigue syndrome.

Chronic fatigue syndrome

Although the name might be new, chronic fatigue syndrome (CFS) is not a new disorder. While the affliction
described as 'neurasthenia' in Victorian times does not
necessarily represent an early forerunner, the 'bed
cases' or 'sofa cases' reported among middle-class
wamen in the period from 1860 to 1910 probably were
CFS and by the time of World War I, a syndrome
resembling CFS was a common complaint in Europe
and North America.' CFS is also known as postviral
fatigue syndrome or myalgic encephalomyelitis (ME).
Although the orthodox medical profession was reluctant at first to recognize CFS as a physical disorder
rather than a variant of depression or neurosis, this
opinion is changing. Nonetheless, treatment of CFS as
a psychiatric problem is still relatively widespread.
CFS was formally defined in 1988 as disabling
fatigue of at least 6 months' duration of uncertain aetiology. Additional symptoms can include mild fever,
sore throat, painful lymph nodes, weight gain, exertional malaise, muscle weakness, muscle and joint
pain, headaches, depression, light-headedness, anxiety, visual and cognitive impairment and disturbed
sleep patterns. It usually has a relatively definite onset
which resembles influenza. Six of these additional
symptoms must be present, plus two or more of the
following signs: low-grade fever, non-exudative
pharyngitis and palpable or tender lymph nodes.2
Currently there is no accepted biochemical test for
the condition. Another problem is that the definition is
somewhat restrictive. Many patients with chronic,
unexplained fatigue and typical symptoms of CFS
may not exactly fulfil the above definition.

Possible causes of chronic fatigue syndrome


The fact that CFS can occur in epidemics has always

pointed to an infectious origin. However, despite
the fact that various researchers have implicated a
number of viruses, a clear association with a single
viral infection has not been established. Originally,
Epstein-Barr virus was thought to be the cause, since
CFS can follow glandular fever. However, clear links
with viral agents remain elusive. Either a number of '
viruses are capable of triggering CFS, in which case
CFS is not an infection in the strict meaning of the
term, or CFS may involve the reactivation of the
immune response to previous viral infections.

-152 -;--a

Pradtal clinical guides

Immunologic abnormalities

The immune abnormalities which occur in CFS are also

inconsistent, perhaps because different viral triggers
may cause different malfunctions. One important study
found no difference between CFS patients and controls
for any white blood cell counts, save the CD8 T-lymphocytes.3 These cells were activated as in a viral infection
and the cytotoxic cell subset was increased. These differences were significant (p=0.01) in patients with major
symptoms of CFS. The study was noteworthy because
of the large number of patients involved and also
because the degree of these changes corresponded to the
severity of the CFS. The authors concluded that immune
activation in CFS leads to increased secretion of
cytokiies which causes the observed symptoms. Their
findings were consistent with chronic stimulation of the
immune system, pcrhaps by a virus. If this is correct, the
feeling of malaise experienced in the early stages of
influenza, when cytokine output is increased, is similar
to the way CFS sufferers feel most of the time. Cancer
patients treated with the cytokine interleukin-2 to boost
immunity experience side effects remarkably similar to
CFS. Serum levels of some cytokines are often raised in
CFS. For example, levels of interleukin-1-alpha:
turnour necrosis factor (TNF)-alphaand TNF-beta5 were
significantly more often increased in CFS patients.
An increased occurrence of autoantibodies such as
rheumatoid factor, thyroid antibodies and antinuclear
antibodies (ANA) has been found in CFS patients.6.7
This, together with an observed high incidence of
circulating immune complexes, led a German research
team to conclude that CFS is associated with or is the
beginning of manifest autoimmune disease.6 These
findings were supported by a large study on 579
patients from Boston and Seattle which found that levels of immune complexes were abnormal in 35% of
CFS patients compared to 2% of controls (p=0.0001)
and ANA was abnormally high in 15% of CFS patients
compared to 0% of controls (p=0.003).8The same study
found that serum cholesterol and IgG levels were also
.significantly raised in CFS.

delivery10 The authors suggested the use of evening

primrose oil and fish oil to decrease non-discocytes.
Regional cerebral blood flows to the cortex and
basal ganglia were significantly reduced in a majority
of CFS patients." This finding is supported by a recent
study in older patients which found that the abnormal
blood flow in CFS was different from that observed in
depression.12 Given the favourable influence of Ginkgo
biloba on both on red blood cell fragility and blood
rheology, it might be indicated for such disturbances.
Brain abnormalities

Magnetic resonance imaging (MRI) scans of the brains

of CFS sufferers found a high incidence of inflammation (oedema and demyelination) in association with
serological evidence of active human herpes virus-6
infection.13 This controversial finding of brain abnormalities in CFS has been somelvhat supported by a
study which observed that CFS patients had significantly more abnormal scans than controls: 27% vs
2Y0.14However, the authors felt that this might instead
indicate that some patients labelled with CFS could
actually be suffering from other medical conditions.
Abnormal MRI and single-photon emission computed
topography (SPECT) scans were found with far
greater frequency in CFS patients compared to normal
Pituitary and hypothalamic abnormalities

Patients with CFS have a mild central adrenal insufficiency secondary to either a deficiency of corticotropin-releasing hormone (CRH) or some other
central stimulus to the pituitary-adrenal axis.16 This
leads to a decreased response of the adrenal cortex.
Abnormalities in the regulation of the hypothalamicpituitary-adrenal (HPA) axis are also a well-recognized feature of endogenous depression. It has been
suggested that, since cytokines potently influence the
HPA axis, their activation may underlie many of the
features found in CFS and depression.17

Circulatory abnormalities

Biochemical abnormalities

A study of 24 CFS patients who were 50 years or

younger found that 100% had slightly abnormal ECG
readings, compared to only 22.4% of controls (p<O.Ol).g
Other research has found that subjects complaining of
chronic fatigue were more likely to have abnormally
shaped (non-discocytic) red blood cells. The authors
concluded that this association with impaired muscle
function could indicate a cause-and-effect relationship,
which would be in agreement with the physiological
concept of fatigue as resulting from inadequate oxygen

It has been hypothesized that the imbalances in

immune function, the HPA axis and the sympathetic
nervous system in CFS can be explained by changes in
essential fatty acid (EFA) metabolism. Dietary EFA
modulation afforded substantial improvement in a
majority of cases.18 A ~apanesestudy did find that
serum concentrations of EFAs were depleted in CFS
sufferers19 and a controlled clinical trial of evening
primrose oil and fish oil demonstrated significant
symptom reduction.20

Herbal approaches to pathological s@tes

Clinical trials
Despite the large number of published studies or. CFS,
there have been very few clinical trials. In particular,
the evening primrose oil study cited above has not
A Japanese
was used
to successful!y treat CFS in an open clinical trial.19
This complex tonifyjng formula included Panax,
Rehmannia, licorice, cinnamon, Astragalus, dong quai
and Schisandra.

Clinical impressions of fatigue
Chronic fatigue syndrome appears to involve a complex interaction between emotional, infectious and
environmental stressors leading to subtle immune
dysfunctions. The extreme debility sometimes ttncountered has the unfortunate effect of blocking many
treatment approaches: rest may be disrupted, exercise
may be debilitating and even the simplest foods may
seem to be too demanding. Many otherwise useful
remedies may be too stimulating or unsettling.
Fatigue may take different forms and arise from
different stresses. There may be a deficiency condition,
there may be an obstruction to normal functions (such
as the effects of clinical depression) or fatigue may follow excessive activity, perhaps marked by anxiety and
nervous stress. The therapeutic approach in each case
will be different. In the first instance, nutritional and
supportive therapies will dominate. In the second,
there may be the need to embark upon substantial constitutional and metabolic strategies. Where tension is
the predominant factor then repair will be difficult if
there is not some relaxant or even sedative relief.
Sometimes benefits will follow a focus on what
could be exacerbating or even causative factors. These
might include:
intestinal dysbiosis, endotoxaemia or similar
allergies or food intolerances;
toxins, e.g. dental amalgam, hair dyes, pesticides;
recurrent fungal, viral or bacterial infection.
Above all else, it is important to ensure that sleep
and rest are adequate and much useful treatment
effort can be directed to this end as a first priority.
Whatever the initiating disturbance, the treatment of
fatigue must be marked by extreme gentleness and

With any fatigue syndrome the fundamental principle
of treatment is to set up an appropriate recuperative

1 ; . "E

regime. Remedies should be set against a wider

programme of convalescence. Convalescence as a
strategy is outlined in Chapter 3. Extensive rest is
essential a,,d may need to be supported by appropriate treatment: exercise, even if minimal, will help
engage adrenosympathetic disturbances; the diet
should be based on the most easily assimilable foods
possible. Only when such a regime is in place can
herbal treatment have a chance of facilitating further
Herbal remedies useful in chronic fatigue syndrome
include the following.
Tonic and adaptogenic herbs

Tonics help revitalize the patient and adaptogens

improve the response to stress. Tonics can also correct
immune function. Although the immune-boosting
function of these herbs might seem unwise, they do
help fatigue syndrome, often dramatically.
Major herbs in this group are:
Panax ginseng: tonic, adaptogenic, stimulates
hypothalamic output and ACTH and hence
adrenal cortex function, increases stamina,
spares muscle use of carbohydrate.
Eleutherococcus senticosl~s:adaptogenic, stimulates
T-lymphocyte function.
Astragalus membraizace~~s:
tonic and immune
Witlzania somnifera: a tonic herb which is not
Adrenal supportive herbs

The main herbs for this purpose are Glycyrrhiza

(licorice) and Rehmanizia gllctil~osn.A case study from
Japan observed that a chronic fatigue patient went
into remission when she developed hyperaldosteronism due to an adrenal turnour. When the adrenal
tumour was removed the fatigue returned.21 Licorice
in high doses can cause pseudoaldosteronism due to
its aldosterone-like action but obviously should not
be used to this level. A high-potassium, low-sodium
diet, as in the Gerson therapy can also raise plasma
Immune-enhancing herbs

Although these may s e e n contraindicated, immuneenhancing herbs are often needed to help prevent the
recurrent viral infections xvhich can plague patients
with chronic fatigue syndrome. Ir'cases of infection,
treatment with tonic herbs may need to be discontinued so that defensive measures can be applied.
Echinacea angustifolia and E. p~rrp~rea
are safe to use

-d*ical clinical guides


since, on current knowledge, they mainly enhance

phagocytic activity. This can improve antigen recognition which leads to better immune responsiveness.
Picrorrhiza kurroa should be used with caution as it is a
poien! promoter of all aspects of immune function, but
it may be indicated for patients who have frequent
viral infections.

Initially, 'Kylie' had difficulty taking the herbal

formula because it was too stimulating. So the dose was
reduced.to half and gradually increased. There was only
slight improvement in her condition for 3 months but
then gradual and steady progress was made. While she
received herbal treatment from time t o time, she was
free of CFS for more than 2 years.

Antiviral herbs

'John' was 35 and had not worked for 3 years. By the

time he sought herbal treatment he complained that he
was getting sicker and sicker. He had constant headaches
and had had chronic sinusitis for about 10 years. His
history showed a previous high exposure t o insecticides
and years of overwork due t o family pressures. His wife
could not cope with his not working and his marriage
was strained. Various formulas were given but the
treatment settled at the following (for 1 week).

Although the viral association is not always clear,

these herbs can be useful in many cases. Hypericum
perforatum (St John's wort) may contribute to antiviral
and antidepressant activity. Thuja occidentalis is also
active against enveloped viruses as well as naked
viruses such as the wart virus and enteroviruses.

Ginkgo biloba, Salvia miltiorrhiza and Zanthoxylum

(prickly ash) will improve blood flow. Ginkgo decreases erythrocyte fragility and improves blood rheology
and short-term memory. Valeriana (valerian), Passiflora
incarnata (passionflower), Piper rnethysticum (kava) and
other such herbs will help the disordered sleep pattern. Crataegus (hawthorn) may help any cardiac and
circulatory abnormalities. EFA therapy with evening
primrose oil and fish oil is recommended.

Panax ginseng
Astragalus membranaceus
Crataegus spp fol.
Ginkgo biloba (standardized)
Picrorrhiza kurroa
Glycyrrhiza glabra
Scutellaria baicalensis

Case histories

In addition, Echinacea angustifolia 1:2 5 ml once a day

was prescribed from time t o time. Also an 'acute formula'
similar t o the one for 'Kylie' was taken during colds and
influenza instead of the basic formula. The Crataegus was
for the headaches and circulation and the Baical skullcap
for the sinusitis. 'John' actually worsened in the first 3
months of treatment, probably because of the natural
progression of the disorder. However, after 5 months he
thanked the friend who recommended herbal treatment
because it was 'the best thing I could have done'. He
gradually improved over a period of several more months.

'Kylie', aged 17, had glandular fever 6 years previously.

Suffered from fatigue ever since, but after beginning
Year 12 at school, fatigue was particularly severe. Often
catching colds and influenza, her attendance was less
than 50%. Even on 'well' days, she often did not have the
energy t o attend school. Herbal treatment consisted of
the following basic formula (written for 1 week).

Astragalus membranaceus
Panax ginseng
Ginkgo biloba (standardized for
Echinacea angustifolia

1 :2
1 :2

30 ml
15 ml

1 :2

20 ml
35 ml
100 ml

Dose 5 mL tds

In addition, Withania 1:2 5 ml once a day was

If a cold came on, the above treatment was stopped
for 3-4 days and the following formula was taken.
Zingiber officinale
Echinacea angustifolia
Euphrasia officinalis
Achillea millefolium

1 :2
10 ml
1 :2
40 ml
20 rnl
30 ml
100 ml
Dose 5 ml with warm water up t o five times a day.

1 :2
1 :2
1 :2
1 :2
1 :2

15 ml
30 ml
20 ml
20 ml
15 ml
20 ml
30 ml
150 ml

Dose 8 ml tds

Plant remedies traditionally used as tonics

Avena sativa (oatstraw),

Cetraria islandica (Iceland moss),
Glycyrrhiza glabra (licorice),
Hypericum perforatum (St John's n-ort),
Medicago sativa (alfalfa),
Serenoa serrulata (saw palmetto),
Swertia chirata (chiretta),
Trigonellafoenum-graecuni (fenugreek),
Turnera aphrodisiaca (damiana),
Verbena oficinalis (vervain),
Withania somnifera.

Herbal approaches to patho~ogic

Indications for tonics

Debilitating conditions with or without anorexia
Chronic fatigue syndrome

Cautions in the use of tonics

The use of tonic herbs may be difficult in the following
Very severe debility especially if associated with
immune or digestive collapse.
Renal or hepatic failure.
Rampant cancer or strong regimes of

The state of digestion is the main determinant of
dosage times. Tonics may be best taken with or after
meals if the stomach and digestive system are weakened; in severe cases, they may need to be taken with
fluid nourishment. Dosage should be rather more than
less frequent: 'little and often' might be a useful axiom.
Long-term therapy with tonics is generally indicated
and often advisable.

In Chinese medicine, tonic remedies are generally
divided into four groups, depending on whether they
are seen to particularly support qi, yang, xue or yin.
The first two groups tend to be warming, the last two
cooling. They are often more dynamic than the tonics
listed above and may thus be more likely to generate
adverse reactions. It is more important, therefore, to
be careful in their prescription and to take close
account of the interpretation of debilitated conditions
that Chinese practitioners use. However, they reflect a
perspective on debility and its treatment that is not
well articulated in the Western traditions.
In the following review, Chinese terms will therefore be used. They are briefly introduced in the summary of Chinese herbal medicine in this text (see p.5)
but any practitioner wishing to apply them should be
well trained in that tradition. Nevertheless, there is
some overlap with Western remedies and some useful
insights are possible for a Western phytotherapist.

associated with such symptoms as fatigue and depression with depressed digestion, diarrhoea, abdominal
pain or tension, visceral prolapse, pale yellow complexion with a tinge of red or purple, pale tongue with
white coating and/or languid, frail or indistinct pulses.
This may lead in turn to a 'damp' condition developing.
In the second case, extreme or prolonged stress
or disease, or chronic pulmonary disease, leads to
depletion or cold in the Lungs, with easy fatigue and
prostration associated with disturbances of regulation,
shortness of breath or shallow breathing, rapid, slow
or little speech, spontaneous perspiration, pallid complexion, dry skin, pale tongue with thin white coating,
weak and depleted pulses.

Plant remedies traditionally used as qi tonics

Panax ginseng (Asiatic ginseng - ren shen)

Codoizopsis pilulosa (dang shen)
Astragalus nzembranaceus (huang qi)
Atractylodes macrocephela (bai zhu)
Zizyphils jujuba (Jujube - da zao)
Glycyrrhiza uralensis (Chinese liquorice - gan cao)

Yang tonics
These remedies support the active energies, particularly
those of the Kidneys (but also Heart and Spleen).
Deficient Kidney yong leads to listlessness with a
feeling of cold and cold extremities, back and loins;
there may be weak legs, poor reproductive function,
frequency of micturition, nocturia, diarrhoea (especially early in the morning), pale complexion and
submerged weak pulses.
Deficiency affecting the Heart involves poor performance and coordination associated with profuse cold
sweating, asthmatic states, thoracic or anginal pain
on exertion, palpitations and fear attacks, cyanosis,
white tongue coating and/or diminished, hesitant or
intermittent pulses.

Plant remedies traditionally used as yang tonics

Trigonellafoenum-groecum (fenugreek - hu lu ba)

Morinda officinalis (ba ji)
Juglans regia (walnut - hu tao ren)
Eucommia ulmoides (du zhong)

Qi tonics

Xue tonics

These support active energies; they are used for

depletion of qi, particularly in the Spleen and Lungs.
In the first case, possibly as a result of prolonged
illness or constitutional weakness, debility may affect
the functions of assimilation and distribution and be

These are remedies that support more substantial

energies, those manifesting in substantial disturbances
or pathologies. By definition, such disturbances are
serious and profound and treatment will need to be
prolonged. Symptoms of depletion of xue may include

cyanosis, pallor, vertigo or tinnitus, palpitations, loss

of memory, insomnia or menstrual problems.
There is considerable overlap with yin tonics.
Plant remedies traditionally used as xue tonics

Angelica sinensis (dang gui)

Rehmannia glutinosa (sheng di huang - fresh - and
shu di huang - prepared)
Paeonia lactiflora (paeony root - bai shao)
Mori alba (mulberry fruit - sang shen)

Yin tonics
Remedies for replenishing the body fluids and essence,
supplying condensed energies and nourishment, for
the most depleted conditions. Areas in most need of
support are the Kidneys, Liver, Lungs and Stomach.
Deficient Kidney yin often follows very serious debilitating disease or, alternatively, extended sexual or alcoholic abuse or overwhelming nervous stress. It may
manifest as a deficient Fire condition, marked by a pale
complexion with red cheeks, red lips, dry mouth, dry
but deeply red tongue, dry throat, hot palms and soles,

palpitations, vertigo or tinnitus, pains in the loins, night

sweats, nocturnal emissions, nightmares, urinary retention, constipation, accelerated though weak pulses.
Deficient Liver yin, usually following the above, is
often associated with dry eyes, poor vision and vertigo
or tinnitus, deafness, muscle twitching, sleeplessness,
hot flushed face with red cheeks, red dry tongue with little coating, diminished, stringy and accelerated pulses.
Deficient Stomach yin is marked by anorexia, regurgitation, thirst, abdominal rumbling, red lips and red
tongue with no coating.
Deficient Lung yin, often following prolonged exposure to dryness or chronic pulmonary disease, is
marked by dry cough, haemoptysis, hoarseness and loss
of voice, strong thirst and/or restlessness and insomnia.
Plant remedies traditionally used as yin tonics

Asparagus cochinchinensis (tian men dong)

Lycium chinensis (gou qi zi)
Panax quinquefoliurn (American ginseng)
Ophiopogonjaponicus (mai men dong)
Ligustrum lucidum (nu zhen zi)
Sesamum indicum (sesame seeds - hei zhi ma)

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