I’m posting some of my essays from my recent course in Chinese Herbal Medicine. They illustrate the thinking process of how we diagnose and treat fever and other conditions with Chinese Medicine. This one is from my final exam. It was a rather short question which made answering difficult but I got a great grade.
Case 2, Final Exam.
Please analysis the clinical case below and give your herbal formula:
Female, 32 years old, first visited on 24th March 2020. She had 4 days fever, her body temperature was not higher than 38°C, and currently is 37.8°C.
Fatigue, dry cough, sweating, chest pain, anxiety and restlessness, very disturbed sleep, poor appetite, and bowel movement 2-3 times a day.
The picture of her tongue is attached.
Analysis of symptoms and signs
Female, 32 years old so presumably is still having a menstrual cycle. We have no details, so I assume this isn’t relevant.
The patient was seen first in March 2020 and is still unwell, so this is a chronic, internal condition.
“Your normal body temperature is approximately 37C. A fever is usually when your body temperature is 37.8C or higher. You may feel warm, cold or shivery.” (Inform, 2022)
So, we can see that after an initial fever with a temperature of 38 degrees Celsius she has now got a low fever of 37.8 degrees Celsius. What we don’t know is whether this is another acute flare up or whether she has a chronic fever. I am assuming it is a chronic fever as this seems to be implied by the question, but we don’t know what pattern this is following.
Chronic fever is defined as fever that persists or recurs over an extended period of time (Maclean, et al., 2018). Fever becomes chronic when it has persisted longer than several weeks, or well beyond the expected time for a particular fever to subside. Chronic fever can persist for months or years and is generally low grade (Maclean, et al., 2018). This would appear to be the case for our case study. The fever can be continuous, or more commonly recurrent following a cyclical pattern, with fever episodes rising in a regular and predictable pattern. The cyclical pattern of the fever can give clues as to its origin in both Chinese medical and biomedical terms (Maclean, et al., 2018). Unfortunately, we don’t have this information.
In Chinese medicine, chronic fever is thought to be associated with ‘internal damage’ (nei shang fa re), traditionally attributed to internally generated pathologies such as deficiencies of qi, blood, yin or yang, or excess pathology such as damp-heat, qi and blood stasis. In clinical practice, however, chronic fevers are often the result of lingering pathogens (Maclean, et al., 2018). It is a possibility that our patient caught Covid in 2020 and has been suffering from Long Covid.
Our case study has fatigue, which may be of an excess or deficient nature (Maciocia, 2004)
She has a dry cough, so we know the Lungs are involved, though any organ can contribute to cough (Maciocia, 2015)
She has chest pain, so we know there is some stagnation of qi and blood in the upper burner.
Anxiety, restlessness, and disturbed sleep suggest the heart and Shen are being disturbed.
She has poor appetite and bowel movement 2 – 3 times a day which shows the Spleen has been injured in some way. This could relate to damp obstructing the qi mechanism, Spleen Qi deficiency, heat or a combination of excess and deficiency.
The tongue has pronounced teeth marks suggesting Spleen Qi deficiency (Maciocia, 2015)
The tip of the tongue is red, possibly with red spots (hard to see on the photo) which suggests heat in the heart and perhaps also Lung. (Maciocia, 2015)
There seem to be red sides to the tongue suggesting Liver/Gallbladder heat. (Maciocia, 2015)
There is a thick greasy yellow tongue coating which suggests Damp-Heat and/or Phlegm. It is particularly thick in the centre and root.
There is sweating which may be from Heat, weakness of the defensive qi layer (wei qi), lung deficiency, dampness, and so on (Maciocia, 2015).
Pathology related to chronic fevers
There are two mechanisms of chronic fever, excess and deficiency. Excess types are due to the persistent presence of a lingering pathogen or to internal organ dysfunction (Maclean, et al., 2018) We certainly seem to have lingering damp, heat and possibly Phlegm. When fever is associated with a lingering pathogen, fever occurs as the body’s anti-pathogenic qi (wei qi) continues to resist, with the ongoing battle between the weakened opponents creating a low-grade fever. In the case of fever from organ system dysfunction, heat is generated by prolonged stagnation of qi, blood, or dampness (Maclean, et al., 2018). In this case, there is certainly interior dampness and stagnation which could also be leading to constrained heat. Fever associated with deficiency is the result of the lack of physiological substrate, and the resulting pathological imbalance that ensues. The symptoms and signs in this case suggest more of a full presentation. That said, there are also signs of deficiency, and these cases are often a mix of the two. The longer the full condition exists, the more the body’s resources are depleted, leading to deficiency.
Aetiology – lingering pathogens.
The patient initially presented having had 4 days of fever. Persistent low-grade fever is common in the aftermath of an acute febrile illness. The fever may persist because the pathogen responsible for the initial episode has not been expelled, its presence has damaged qi and/or yin, or because it has congealed fluids into phlegm-heat or damp-heat (Maclean, et al., 2018). The latter seems to be the case for our case study.
- Lingering heat in the Qi level – persistent low-grade fever in the aftermath of an upper respiratory or gastrointestinal tract infection. Consistent with our case are the symptoms and signs of persistent low-grade fever, insomnia, restlessness, fitful sleep, fatigue dry irritating cough, sweating, stifling sensation in the chest. But you would expect to see a slightly pale to slightly red and dry tongue with little or no coat or a patchy coat. (Maclean, et al., 2018)
- Shao Yang syndrome. The shao yang level is the transitional zone between the surface and interior of the body where pathogens can persist for considerable periods of time. An equilibrium state is created whereby the normal qi is unable to eject the pathogen, with the pathogen contained and unable to penetrate further. The containment process consumes qi and heat damages yin. The nature of the pathogen varies the intensity of the fever. When heat alone is involved, the fever is prominent and obvious. When damp-heat is involved, fever episodes are cyclical, low-grade, or contained (Maclean, et al., 2018). We don’t know if the fever in this case is cyclical. We do know there is reduced appetite, fatigue, fullness in the chest, irritability/restlessness, red sides to the tongue. With damp-heat there may be sweating
- Damp-Heat – a sticky, viscous pathogen, damp-heat can linger for long periods of time and occupy the qi level or specific organ systems (Maclean, et al., 2018). Consistent with our case are signs of lingering low-grade fever, sweating, fatigue, loss of appetite, loose stools, thick, greasy coat which may be white or yellow. But this wouldn’t explain the chest pain, dry cough, anxiety and restlessness, disturbed sleep.
- Phlegm-Heat affecting the Stomach and Heart. Whilst less commonly associated with a chronic fever, this syndrome has the signs of insomnia, very disturbed sleep, anxiety, and restlessness, stifling sensation in the chest, poor appetite, spontaneous sweating and a thick, greasy, yellow tongue coat.
I think the patient has lingering pathogens of heat and damp/phlegm that have settled at the stomach and heart. Either heat from an initial invasion entered the qi level and mixed with pre-existing dampness in the middle burner or a damp-heat pathogen lodged in the interior leading to obstruction of the qi mechanism and constrained heat.
We are essentially seeing the pattern of phlegm- heat affecting the stomach and heart. As discussed, the centre is weak with Spleen qi deficiency.
Phlegm- heat in the heart and chest can be a cause also of chest pain. The sticky thickness of Phlegm obstructs yang qi distribution and readily generates heat. Prolonged heat from other pathology such as qi constraint or yin deficiency can cook phlegm into phlegm-heat (Maclean, et al., 2018). There will be stifling or suffocating sense of oppression of the chest, chest pain, or a feeling of heaviness or a weight on the chest. The tongue is slightly red with a greasy, yellow coat. There are sleep disturbances and anxiety. (Maclean, et al., 2018)
The dry cough is a bit of a puzzle as phlegm-heat would likely show as a productive cough. It could be that the phlegm is too hard to expectorate, or more likely that heat is invading the lung from the liver. Some of the herbs below drain and clear constrained heat and should relieve this. However, the cough may need to be addressed more directly in the future.
Move qi and dissolve Phlegm, clear congested heat in Shao yang, strengthen the centre (Fruehauf, n.d.)
Or in other words: Clear Heat and transform Phlegm, harmonise the stomach and calm the Shen (Maclean, et al., 2018)
WEN DANG TANG – Warm the Gallbladder decoction
Modification – addition of huang lian and shan zhi zi for irritability and restlessness.
- Zhu ru 12g
- Zhi shi 9g
- Zhi ban xia 9g
- Fu ling 12 g
- Chen pi 9g
- Sheng jian 3g
- Gan cao 3g
- Da zao 3 fruit
- Huang lian 3g
- Shan zhi zi 6g
Decoction, one packet a day (in 2 doses).
Discussion of herbs:
- Zhu ru clears phlegm heat and directs stomach qi downward
- Zhi shi breaks up stagnant qi, directs qi downward and alleviates distension
- Zhi ban xia transforms phlegm-dampness and directs stomach qi downwards
- Chen pi transforms phlegm, regulates middle burner qi, and restores the qi dynamic
- Fu ling strengthens the spleen and leaches dampness
- Gan cao strengthens the spleen and harmonises the stomach
- Sheng jian assists the other herbs in transforming the Phlegm (Maclean, et al., 2018)
- Huang lian cools heat, drains fire (especially in the heart and stomach) and dries dampness (Bensky, et al., 2015)
- Shan zhi zi resolves constrained heat, directs damp-heat downward and out through the urine. It drains heat and eliminates irritability for heat patterns with fever, irritability, restlessness, stifling sensation in the chest, and insomnia (Bensky, et al., 2015).
Wen dan tang represents one of the most common remedies for phlegm disorders of all kinds. The earliest version was first recorded in Sun Simiao’s7th century medical primer (Golden mirror of the medical tradition) but achieved the form that is most favoured today only during the 18th century. While it can treat various manifestations of phlegm in the digestive and respiratory tracts, it has emerged as one of the best-known psychoactive remedies for conditions involving phlegm. It is therefore often used for digestive conditions involving brain chemistry imbalances, such as anxiety depression, insomnia, ADHD, epilepsy, and Tourette’s syndrome (Fruehauf, n.d.)
While this formula’s name is Warm Gallbladder Decoction (wen dan tang), in fact, the nature of the medicinals that comprise it are not at all warm or hot; actually, it has a rather good sedative effect. The original text records this prescription as primarily treating those who “are easily startled by events, have dream-disturbed sleep, palpitations and fatigue, or spontaneous sweating” (Huang, 1994).
In the long term, once the Phlegm and Heat have resolved, a more tonifying formula may be needed to strengthen the Spleen Qi.
Bensky, D., Scheid, V., Ellis, A. & Barolet, R., 2015. Chinese Herbal Medicine, Formulas & Strategies.. 2nd Edition ed. Seattle: Eastland Press.
Fruehauf, H., n.d. Chinese Herbal Formulas: A clinical handbook. 2nd Edition ed. Portland: Heishan Press.
Huang, H., 1994. Ten Key Formula Families in Chinese Medicine. 1st Edition ed. Seattle: Eastland Press.
Inform, N., 2022. Fever in adults. [Online]
Available at: https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/fever-in-adults
[Accessed 18 September 2022].
Maciocia, G., 2004. Diagnosis in Chinese Medicine A Comprehensive Guide. 1st Edition ed. s.l.:Elsevier.
Maciocia, G., 2015. The Foundations of Chinese Medicine A Comprehensive Text. 3rd Edition ed. s.l.:Elsevier.
Maclean, W., Lyttleton, J., Bayley, M. & Taylor, K., 2018. Clinical Handbook of Internal Medicine. 2nd Edition ed. Seattle: Eastland Press.