Most people today are living extremely stressful, busy lives, so it is normal to experience tiredness some of the time. This tiredness generally resolves itself after some rest and relaxation. Increasingly though, persistent tiredness is becoming a major problem for a number of people. Fatigue is a common presenting complaint of the majority of Australians and New Zealanders, but it is also often misunderstood and at times even dismissed, particularly if there is no easily identifiable cause. Up to 20% of the general population suffers from fatigue lasting longer than one month, and up to 10% suffer from fatigue for longer than six months. Chronic Fatigue Syndrome (CFS) is a condition characterised by prolonged, disabling fatigue lasting longer than six months, extremely low stamina, weakness, muscle pain, lymph node swelling, depression and other mood symptoms. 

FATIGUE AND THE TRADITIONAL CATEGORIES OF XU LAO (VACUITY TAXATION) AND BAI HE BING (LILY DISEASE)

In TCM there are several approaches for pattern differentiation and treatment strategies of CFS. As the term Chronic Fatigue Syndrome is quite recent, attempts of pattern differentiation are a summary of modern clinical practice only. There are, however, two traditional categories for disabling fatigue that does not go away with mere rest. These two categories, Xu Lao (vacuity taxation) and Bai He Bing (Lily Disease) are examined below. As Dr. Dharmananda mentions in his article on Bai He Bing (Lily Disease), “it is not always possible to separate organic diseases from others that might be termed psychosomatic, neurotic, or related to behaviour and thought patterns. As an example, the condition known as CFS has been very difficult for medical researchers to study because there is such a diverse range of physical and mental conditions that are presented by those who claim to be suffering from it. Among them are persons who are simply depressed or living an erratic lifestyle that brings about fatigue, and there are others who have some kind of viral infection (or group of viruses) that may be identified as the culprit. The infectious agents can wreak havoc on the immune system and cause fatigue as a side effect, but so can emotional disturbances and the adverse effects of certain activities and difficult experiences.” Chinese physicians have dealt with complex patients and difficult to diagnose diseases, such as those depicted above, for many centuries. Two Traditional Chinese Medicine categories including severe fatigue as a major symptom are Xu Lao, translated as Vacuity Taxation, and Bai He Bing, translated as Lily Disease. “Xu Lao” is defined as any pattern of severe vacuity and refers to a chronic state of fatigue and exhaustion that does not go away by merely resting. Bai He Bing, translated as Lily Disease,is distinguished by “desire but inability”, a desire but inability to eat, talk, lie down, walk or perform other activities. Again, this state does not respond to mere rest. 

BAI HE BING – LILY DISEASE

Bai He Bing literally means “lily bulb disease”. It was named after the main medicinal used to treat it, Bulbus Lilii (Bai He). This disorder was first described Zhang Zhong Jing in the medical classic, Jin Gui Yao Lue (Essentials from the Golden Cabinet). Bai He Bing is a disease characterised by general malaise - a desire but inability to eat, talk, lie down, or walk. Patients complain of feeling cold, then not cold, feeling hot and then not hot again, crave food at one moment and then don't want to eat, and are generally confused about what they want. They appear aloof, lethargic and lifeless. The patient also has unusual reactions to herbs, and tends to react with digestive upsets to formulas that should be able to help. Other symptoms are concentrated urine, general signs of yin vacuity, and particularly restlessness. Due to the symptoms and the medicinals chosen, these days Bai He Bing is thought to be primarily heart and lung yin deficiency. 

COMMON ETIOLOGICAL FACTORS: FEBRILE DISEASE 

Evil heat causes a loss of fluids through profuse sweating and/or profuse vomiting. Vacuity heat then dries out the lung and the heart. The po and the shen are poorly nourished and insufficiently anchored and they become restless, producing mental depression, anxiety, mental fatigue and confusion. In the aftermath of a febrile disease, enduring residual heat burns and coagulates fluids into phlegm. If phlegmheat accumulates in the lung, it damages lung yin, which then does not correctly anchor the po. Heat, which rises by nature, upbears phlegm, which then clouds the heart and causes restlessness of the shen.  

COMMON ETIOLOGICAL FACTORS: EMOTIONAL DISTURBANCE

Any emotion misunderstood and believed in can transform into emotional fire that, because of its nature, ascends towards the upper burner and damages the heart and lung yin. Heart and lung yin vacuity causes insufficient nourishment of the shen and the po. They are not sufficiently anchored, and become restless. Enduring sorrow, chronic anxiety, and frequent depressive states, can damage the lung and heart qi and induce lily bulb disorders. A key point is that the lung and heart are affected and, by extension, po and the shen. Bai He Di Huang Tang [Lily and Rehmannia Combination] is the core formula of the four classic Bai He decoctions mentioned in the Jin Gui Yao Lue, or “Essentials from the Golden Cabinet”, chapter on ¡¥Lily disease'. Bai He Di Huang Tang [Lily and Rehmannia Combination] moistens heart and lung yin, clears deficiency heat, and calms the spirit. It consists of Bai He [Lily] and Sheng Di Huang [Raw Rehmannia]. Bai He clears heat and calms the spirit, and moistens the lung, Sheng Di clears heat, cools the blood, nourishes yin and generates fluids, and cools heart fire flaring up. 

INDICATIONS FOR BAI HE DI HUANG TANG 

A patient who is depressed, does not like to talk, and is confused about what they want or what they feel. Chronic fatigue and weakness after minor mental or physical effort, loss of memory, generalised aches and pains, depression, changeable moodiness, manic depressive disorders, anxiety, some eating disorders. T: red, with little or no coat P: fine, slightly rapid. 

COMMON MODIFICATIONS OR COMBINATIONS 

Bai He Zhi Mu Tang (Lily & Anemarrhenae Decoction): Bai He (Lily) 18-45 g, Zhi Mu (Anemarrhena) 9 g. 

• Therapeutic principles: To engender heart yin and fluids. 
• Symptoms and signs: Indications for Bai He Di Huang Tang with insomnia, a lot of dreams, anxiety, palpitations, easily, startled and frightened, patient feels hot, this may be the result of a febrile condition. 

Bai He Di Huang Tang with Gan Mai Da Zao Tang [Licorice & Jujube Combination] 

• Symptoms and signs: Indications for Bai He Di Huang Tang with depression (particularly for women), unrealisable desires, easily crying and laughing, restlessness, P: thready, rapid.

Bai He Di Huang Tang with Suan Zao Ren Tang [Zizyphus Combination] 

• Symptoms and signs: Indications for Bai He Di Huang Tang with great mental stress, poor sleep, depression, deficiency, restlessness, hot palms (perhaps heat sensations elsewhere), dry mouth, T: deep red. 

Bai He Di Huang Tang with Gui Pi Tang [Ginseng & Longan Combination] 

• Symptoms and signs: Indications for Bai He Di Huang Tang with insomnia (particularly difficulty falling asleep), inability to concentrate, easily distracted. 

Bai He Di Huang Tang with Ban Xia Hou Pu Tang [Pinellia & Magnolia Combination] 

• Symptoms and signs: Indications for Bai He Di Huang Tang with a sensation of a lump in the throat, that can't be swallowed down or spat up, stuffiness in the chest, hypochondriac distention, sighs a lot, T: thick coat. 

Bai He Di Huang Tang with Gui Zhi Jia Long Gu Mu Li Tang [Cinnamon & Dragon Bone Combination] 

• Symptoms and signs: Indications for Bai He Di Huang Tang with easily frightened, very restless, dream disturbed sleep, may be sexual or fearful dreams, sexual dysfunction, insomnia, may be fearful of going to bed, P: hollow, slow. 

CLINICAL STUDY OF COMBINATION OF BAI HE DI HUANG TANG, SI JUN ZI TANG & XIAO YAO SAN FOR CFS

In the Shanghai Journal of Traditional Chinese Medicine, the Chinese physician Yin Hengze designed a formula for Chronic Fatigue Syndrome based on combining Bai He Di Huang Tang [Lily and Rehmannia Combination], Si Jun Zi Tang [Four Major Herb Combination], and Xiao Yao San [Bupleurum & Dang Gui Formula]. The patients, suffering from a variety of symptoms including constant fatigue after any activity, difficulty concentrating, depression, sleep disorder, aches and pains, sore throats, etc., were treated with both the above formula combination and psychotherapy. It was reported that two weeks of this treatment would produce a symptom resolution in about 75% of the patients. 

XU LAO – VACUITY TAXATION 

Xu Lao is any pattern of severe vacuity and refers to a chronic state of fatigue and exhaustion that does not go away by merely resting. “Xu” means, of course, deficiency, and “lao” means “tiredness”, hence the term means “tiredness from deficiency”. 

COMMON ETIOLOGICAL FACTORS 

• Weak constitution with resulting vacuity. A weak constitution can manifest in any of the five zang organs, not merely the kidneys, hence it is important to establish chronic weak points in childhood, e.g. digestive weakness, poor appetite, tiredness and weak muscles in childhood point to a weak spleen constitution, frequent colds and chest infections during childhood point to a weak lung constitution, nearsightedness and headaches in childhood are associated with weak liver, and a nervous child that has sleep disturbances may point to a weak heart.
• Mental or physical overwork. This is often due to inadequate rest, e.g. some activities we associate with rest may in fact not be nourishing and regenerating such as watching TV until late at night, work-outs in gyms that are too draining, etc. Different types of overwork tends to deplete in different ways, e.g. working under stress tends to deplete yin, mental overwork tends to deplete the spleen, staring at a computer screen for long hours depletes liver and heart blood, and physical overwork depletes the kidneys. 
• Unsuitable diet harming spleen and stomach. This includes eating under stress (work lunches or dinners), eating at irregular times, skipping meals, radical or unsuitable weight loss diets, eating not balanced e.g. too greasy, too much raw food, too much processed foods. 
• Prolonged or serious disease and failure to rest and recover properly. This is very common and includes post  viral symptoms. Although certainly not a disease, failure to recover properly from childbirth also often leads to vacuity taxation, a fact that is stressed in all traditional societies. 
• Untreated or mistreated disease damaging the essence. 

TRADITIONAL VIEWS ON TREATMENT STRATEGIES 

Li Dong Yuan (author of “Pi Wei Lun”) held the view that spleen and stomach deficiency should be at the centre of treatment. Zhu Dan Xi (author of “Secrets of Dan Xi”) placed his focus on kidney and liver yin deficiency. Zhang Jie Bin (author of “Classic of Categories” and “Complete Book of Jing Yue” focused on kidney supplementation, and Zhu Qi Shi advocated treating lungs, spleen and kidneys. Ming Dynasty physician Sun Yi Kui believed that although all organs can be affected by vacuity taxation, usually the heart and kidneys are affected foremost. He based his view on the theory that the heart governs the blood, the kidneys govern essence. If essence is used up, the blood will be dry, resulting in both kidney and heart being vacuous. Sun Yi Kui liked using Ren Shen [Ginseng] because it does not only supplement qi, it also supplements blood by increasing the potency of other blood-supplementing medicinals. Sheng Di Huang [Raw Rehmannia], Shu Di Huang [Cooked Rehmannia] and Dang Gui [Angelica Sinensis] help yin and engender blood, Bai Shao [White Peony] nourishes and Chi Shao [Red Peony] moves blood. These medicinals can be found in a large percentage of Sun Yi Kui's prescriptions treating Xu Lao. Other medicinals that are often used include Shan Yao [Dioscorea], Gou Qi Zi [Lycium Fruit], and E Jiao [Ass Hide Gelatin]. 

SUPPLEMENTATION WITH CARE 

Although a pattern of severe vacuity requires supplementation, obstructions such as phlegm or exterior pathogenic factors have to be eliminated. Patients with severe vacuity are prone to exterior invasion of pathogenic factors that lodge in the shaoyang, which will require the use of harmonising formulas. It is also important to protect and strengthen stomach and spleen before using kidney supplementing formulas. 

A CASE STUDY EXEMPLIFYING THE MISUSE OF SUPPLEMENTATION

Patient experiencing fatigue and fever in the afternoons that lasts until the early morning hours. The fever intensifies at night. Other symptoms are distending pain in the right ribside and coughing fits that hurt. He was diagnosed with malaria and treated accordingly for 20 days without result. He then was treated according to vacuity heat with supplementing medicinals, which intensified his ribside pain. Pulse: Left large wiry, right large slippery. His appetite worsened progressively, and his spirits and energy were very low. A new doctor treated him with Zhang Zhongjing's Xiao Xian Xong Tang (Minor Sinking Into the Chest Decoction) which clears heat and transforms phlegm, and treats focal distention and pain at the chest due to knotted phlegm and heat. The ingredients are Gua Lou Shi [Trichosanthes Fruit], Ban Xia [Pinellia], Huang Lian [Coptis], to which the doctor added Qian Hu [Peucedanum] and Qing Pi [Blue Citrus]. In the evening the patient had to take another formula called Dang Gui Long Hui Wan (Tangkuei, Gentiana Longdancao and Aloe Pill), a formula clearing liver and gallbladder heat and abducting fire. At midnight the pain had already reduced by 50%, the fever abated and all other symptoms improved. This illustrates the importance of elimination of obstructions and pathogenic factors before supplementing.

CLINICAL STUDY OF CFS TREATED AS XU LAO (VACUITY TAXATION) BY ZHUO LI-YONG 

According to Dr. Zhuo, CFS corresponds to the traditional Chinese disease category of vacuity taxation. 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. The total effective rate was 89.4%. According to Chinese medical theory, the kidneys govern the storage of essence. 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 becomes 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. Liu Wei Di Huang Wan originated in the Tang dynasty and its functions are to enrich and supplement the liver and kidneys. Dr. Zhuo used a modified version of Liu Wei Di Huang Wan, containing: Shu Di Huang (cooked Rehmannia)15 g, Shan Yao (Dioscorea) 24 g, Fu Ling (Hoelen)12 g, Huang Qi (Astragalus) 24 g, Xian He Cao (Herba Agrimoniae) 30 g, Shan Zhu Yu (Cornus) 10 g, Ze Xie (Alismatis) 12 g, Yin Yang Huo (Epimedium) 15 g, Tu Si Zi (Cuscuta) 24 g, Shi Hu (Herba Dendrobii) 15 g, Da Zao (Jujube) 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. 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) 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 qisupplementing medicinal. It is able to boost the qi and rectify the blood. It also promotes a 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.