CHINESE HERBAL TREATMENT FOR MULTIPLE SCLEROSIS
AND OTHER FLACCIDITY SYNDROMES, INCLUDING MYASTHENIA GRAVIS AND AMYOTROPHIC LATERAL SCLEROSIS.
by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon
A NEW DISEASE
Multiple sclerosis (MS) is a modern disease. It may have occurred in earlier centuries, but theoretical and diagnostic limitations made it impossible to clearly define this disease. The earliest recorded medical discussions of MS are at the end of the last century, and it is difficult to trace potential cases of the disorder more than a few decades before that.
The use of “sclerosis” in the disease name is in reference to the scarring of the nerves (formation of plaques, where myelin no longer forms) of the central nervous system (CNS) that results from inflammation and subsequent destruction of their myelin sheaths. The detection of demyelination in living persons requires the most modern of medical techniques. Until the development of magnetic resonance imaging (MRI) in the early 1980’s, confirmation that a person suffered from MS had to await autopsy, though the disease could be guessed with some reliability by a comprehensive description of its course and manifestations. One test, the hot bath diagnostic procedure, was used for about fifty years (until MRI became prevalent): persons with MS would usually display more severe symptoms after exposure to a hot bath.
The onset of the disease is insidious and its course is highly variable over time. In some cases, minor neurological disturbances precede the more characteristic flare-ups (called exacerbations) by several years. Symptoms may be quite different among individuals. Weakening of the legs, bladder, and colon—muscles in the lower body—are common, but so are mental fogginess and optic neuritis—indicating brain damage. The term ‘multiple’ is used because many nerves are affected, but the disease might show evident impact on only a single muscle group during the first years of development. Even with modern technology, a firm diagnosis of MS is not easily established by physicians until it has reached a somewhat advanced stage—sometimes a decade or more after the onset of troublesome symptoms. The average age at diagnosis of MS in the U.S. is about 31.
IMMUNOLOGICAL NATURE OF THE DISEASE
An extensive review of the immunological disturbance in MS was presented by Byron Waksman of the New York chapter of the Multiple Sclerosis Society in 1986 (1). The chronic nature of the disease appears to be linked to the presence of a specific gene belonging to the major histocompatibility complex (MHC) that results in susceptibility to the disease. Individuals without this genetic background may suffer from acute demyelinating diseases (such as Guillain-Barre syndrome) without experiencing relapse and progressive deterioration, as occurs with MS. Other autoimmune diseases, such as insulin-dependent diabetes, myasthenia gravis, thyroiditis, and chronic ulcerative colitis, often occur in the same individuals who experience MS, or in their parents, siblings, or children, as a result of the genetic background that predisposes the individual to autoimmune disease. The child of a parent that has MS has about a 40 times higher risk of developing MS than others (2).
MS is a rare disease in China, Japan, and other parts of Asia. Similarly, the disease is not found among African blacks (but is found among a small proportion of American blacks who have Caucasian ancestors), Eskimos, and several other population groups. It occurs with fairly high frequency in the Caucasian population, with about 75% of cases being female (in China, it appears that only about 50% of cases are female). In the U.S., the incidence rate for MS is estimated to be about 0.08–0.12% of the population (about 250,000–350,000 cases at present), but it is about 0.3–0.4% of Caucasian women over the age of 30. There are clear genetic influences not only on the incidence of the disease among races and within families, but also on the tendency to suffer certain symptoms of the disease. Differences between Japanese and American patients in the main site of attack against the central nervous system have been noted: 50% of Japanese cases of MS involve the optic nerve and spinal cord only, and another 33% of the cases additionally involve the cerebrum; among Americans, the comparable figures are 13% and 66%, respectively.
It is apparent that viruses play a role in both the development of the disease and its flare-ups. It has been proposed that during an immune attack against one or more of the common viral infections, a T-cell line is established that, when activated, attacks myelin, with myelin basic protein (BP) as one of the key sites of attack. This may occur even if the virus does not enter the nervous system (the primed T-cells from the peripheral blood can attack myelin so long as the T-cell surface receptor has a close enough match to myelin BP). A possible risk factor for developing the disease is late experience—close to time of puberty—of common childhood infections, such as rubella, measles, and mumps. Measles, in particular, appears to be an initiating virus.
It is possible, but not demonstrated, that immunization against these childhood viral diseases may prevent them from acting as initiators of MS; it is too soon after the introduction of mass immunizations to tell the effects (though we should know soon). Even so, other viruses may replace those mentioned above in the role of MS initiation. For example, HHV-6, a herpes virus that causes the childhood disorder called roseola, and which may exist undetected in a large portion of the population, appears to be involved in several other diseases and has been suggested to be one of the potential culprits in MS, since the virus is found in the oligodendrocytes of MS patients (30). The virus is found in the region of the MS plaques but not the unaffected parts. While HHV-6 is found in persons without MS, it is not found in the oligodendrocytes in otherwise healthy people. HHV-6 infects both the T-cells, altering their activity, and the central nervous system. CNS infections with the virus are associated with multifocal demyelination and can produce a disease that appears identical to MS (31). Interest in HHV-6 has been stimulated by findings that it can co-infect cells that are infected by human immunodeficiency virus (HIV) and can activate replication of that virus (it is thus called a transactivator). It is possible that HHV-6 plays a role in MS in conjunction with other viruses.
Interestingly, the incidence of MS is higher (within the Caucasian population) in the far northern and far southern latitudes towards the earth’s poles. From this observation, it has been suggested that where one lives around the time of puberty may be the key factor in disease initiation, as opposed to where one lives when the disease manifests obvious symptoms. The risk at puberty might be related to growth of the central nervous system and changes in immune responses under the influence of hormones during that stage of development. The uneven distribution of MS cases around the world has been suggested to be related to exposure to viruses or bacteria from animals, such as dairy cows or dogs (3). In one instance, islands in the North Atlantic that were free of MS showed a high incidence of MS cases a few years after army garrisons had been on the island for a while, implicating an infectious agent carried by the army members or their accompanying dogs or other livestock.
It has also been suggested that deficiencies in certain nutrients (such as calcium, vitamin D, vitamin B12, selenium, and essential fatty acids) during the development of the nervous tissues may enhance risk for suffering from MS (4). The metabolism of vitamin D and calcium are influenced by sun exposure, and there can be dietary factors influencing availability of all these nutrients that may vary by location and culture.
During the 1980’s, some observers revived the earlier proposal that MS was the result of a spirochetal (bacterial) infection of the CNS. In part, this was because of the newly identified Lyme Disease, caused by a tick-borne spirochete, and it has a regional occurrence (favoring northern deciduous forests) and autoimmune-like character (5). The earlier hypothesis, proposed in 1909 and considered a possibility through the 1950’s, was that MS might have been due to another spirochete, the one that causes neurosyphilis, or one like it. Thus far, a bacterial infection has not been shown to be the immediate cause of MS, but the several decades long history of proposals that MS is initiated by an infection shows a consistent understanding that the disease is not solely based on genetics, climate, emotions, or other non-infection etiologies. By contrast, the neuromuscular Charot-Marie-Tooth disease, which also causes weakening and wasting of the leg muscles and, later in its development, other peripheral muscles, appears to be based primarily on genetic background.
Once T-cells aimed at myelin sheath surface proteins have developed, later infections, not necessarily the same as the initiating virus, can trigger a subsequent flare-up of the autoimmune disease. Many patients observe a close connection between experience of influenza or common cold and symptoms of the disease, and this connection is documented (32). It has been proposed that flare-ups that do not appear to follow an infection actually follow either an infection that did not manifest overt symptoms or activation of a latent virus (such as one of those in the herpes family) without evident symptoms. A successful immune response to the infectious agent may have prevented the symptoms from developing, but then continued on to attack the myelin.
Not only viruses, but other types of infections, such as bacteria or parasites, might induce MS exacerbations (6). Several viral and bacterial peptides have been shown to activate T-cells that were primed to attack myelin BP. Chronic sinusitis has been strongly associated with MS, with the possibility that the sinus infection (which can be viral or bacterial) induces an immune response that eventually promotes the attack against myelin.
It has recently been suggested that the cytokine called tumor necrosis factor (TNF) is associated with production of multiple sclerosis symptoms (7). This cytokine is found in the myelin lesions and cerebral spinal fluid of MS patients. TNF, and other cytokines (e.g., interleukins 1,4, and 10, and interferon gamma) that might act concurrently, are induced in several infectious and parasitic diseases. HHV-6 is a powerful inducer of TNF in peripheral blood mononuclear cells (43). Interferon gamma and TNF slow the suppression of immune attack. As a result, an immune attack against a minor infection may be prolonged until myelin is also attacked, and the action of the cytokines may then prolong the MS exacerbation. The antidepressant drug rolipram is a TNF inhibitor that has been suggested as a useful therapy for MS (8); several other drugs have been revealed to have anti-TNF activity in recent years, including: ketotifen (used for treating asthma), thalidomide (a sedative), and pentoxiphyllene (used for treating blood clotting in peripheral vessels); some of these could also be of benefit for persons with MS (the selection of drugs allows choice among the primary indications for their use). Interferon beta (provided as the drug betaseron), inhibits interferon gamma and TNF and aids the function of suppressor T-cells.
In the cerebral spinal fluid of MS patients, it has been found that there is a significantly higher level of aldehydes, including formaldehyde (33). These aldehydes can cause protein cross-linking (thereby making the proteins physiologically inactive) and block nerve impulses. Their action is more evident at higher temperatures, which may partly explain the hot-bath phenomenon in persons with MS. The high levels of aldehydes may be associated with the observed phenomena of reduced antioxidant activity in persons with MS, suggesting a role for oxidative stress in the susceptibility to or expression of exacerbations (34).
It has been proposed that weakening of the blood-brain barrier may permit easier access of low density lipoproteins (LDL) and other substances to the cerebral-spinal fluid that make the myelin more susceptible to oxidative damage and immune system attack (35). LDL tends to be high in persons who are physically in active and in those who consume large amounts of saturated fats. According to this line of thought, agents that promote greater integrity of this barrier could slow the progression of MS by limiting inappropriate access to the nerves. Administration of antioxidants, including vitamin C, vitamin E, and glutathione have been shown to improve the antioxidant activity (36), but have not yet been tested long enough to demonstrate an impact on the frequency, severity, or duration of exacerbations.
In most cases, an infection (or other inducing agent) initiates an autoimmune attack or enhances an ongoing attack that produces notable symptoms. These symptoms may last for a few days to a few weeks in the remitting type of MS. Within a few days of the immune activation, the natural regulation of the immune system—which may be inhibited due to host factors or the influence of chronic viral infection—produces a withdrawal of the attack, and there can then be recovery of the damaged nerves (which is quicker, as with other injuries, with youth and good nutritional status). With each exacerbation (autoimmune attack), there is local vascular inflammation (in the area of the CNS), usually with severe local edema, followed by demyelination of the affected nerves, resulting in scarring if the attack is sufficiently severe (remyelination of the nerves can occur if there is limited damage). Steroids administered at the onset of an exacerbation may reduce demyelination, but long-term administration offers little benefit. In persons who respond poorly to steroids, it is possible that processes other than immune attack and inflammation, such as aldehyde formation and oxidative stress, continue to enforce the nerve damage.
The process of demyelination is one of the causes of muscular weakening or numbness: nerve transmission via the affected nerves is disrupted. Even so, areas of plaques as seen by MRI, which represent essentially irreversible damage, do not necessarily cause persistent interference with nerve transmission. Some individuals show little or no symptoms even with extensive plaque formation, while others show significant impairment with little evidence of plaques. This is probably because there are other mechanisms of nerve inhibition and because the nervous system is sometimes able to develop alternative routes of transmitting the essential information. However, once the damage from repeated attacks has reached a certain level of severity, the disease manifestation (e.g., muscular weakening) in most individuals becomes continuous rather than intermittent. Further, when a person is debilitated for an extended period of time, they may cease the attempt at movement and thus deprive the nervous system of the stimulus needed to reroute signals.
There are at least two types of MS disease described by the course of development. The intermittent type (or relapsing-remitting) is one in which there are flare-ups of the attack against myelin followed by a period of recovery, often with several weeks, months, and sometimes years, before the next attack. The average rate of exacerbations during the first years after diagnosis is about 1.25/year. In a few cases, the cycle of attacks appears to end spontaneously and there may be few, if any, residual symptoms; the MS does not progress to a more serious or paralytic condition. The progressive type usually follows a course of steadily worsening debility, where there may be only a few days of relative relief, followed by continued progression of the disease. This type leads to severely impaired immobility and eventually to death; fortunately, it is the less common form. With current therapies that can benefit persons with MS (when applied in a timely manner), the main long-term problem may be deterioration of health due to lack of exercise, with accumulation of secondary diseases.
In sum, persons who experience MS usually have a genetic background that makes this particular disease more likely. They then experience an infection (or combination of infections) that establishes the possibility of autoimmune attacks against myelin. A combination of other factors then converge to enable the disease process: these may include nutritional deficiencies, damage to the blood-brain barrier, low antioxidant potential, and chronic CNS infection. Finally, the disease manifests in a series of exacerbations, usually induced by acute infections, turning into a progressive, non-remitting disease when and if the immune system loses its ability to withdraw the antimyelin attack or when other processes (such as accumulation of oxidized fats) continue to damage myelin. While this scenario may need to be updated somewhat as additional information is acquired, it is sufficient to suggest several methods of therapy, some of which have already provided help to persons with MS.
Before turning to the Chinese medical analysis of the disease, it is worth mentioning some other diseases that have related characteristics. Since MS is not a frequent disease in China, experience treating several other disorders that have muscular weakening and autoimmune processes in common, may help to add to our knowledge of successful approaches. Myasthenia gravis (MG) produces symptoms of muscular weakness; like MS, it is insidious, variable, and potentially fatal (in the progressive form of the disease). MG appears to be initiated by a virus, but the site of attack by the activated T-cells is different than with MS—the acetylcholine receptors of the nerves are affected. The motor neuron degenerative diseases also share some similarities with MS. In one, amyotrophic lateral sclerosis (ALS), the muscular weakness usually begins in the hands and spreads to the forearms and legs. This is accompanied by (and often preceded by) spasms and increased tendon reflexes. The site of autoimmune attack appears to be mainly the anterior horns of the motor neurons; the brain functions are not affected. Unlike MS and MG, it does not often display extended periods of remission, rather, it tends to progress rapidly, often leading to death within 5–6 years. A more benign form of this disease is progressive spinal muscular atrophy, which causes muscle wasting and weakness, but does not cause significant shortening of lifespan.
CHINESE MEDICAL THEORIES
In the most ancient Chinese medical texts, and in many subsequent works, there are some references to diseases with symptoms of muscular weakening. These are called weizheng: flaccidity syndromes. There are four basic causes of, or contributors to, the development of these syndromes:
<![if !supportLists]>1. <![endif]>A feverish disease (now understood to be caused by an infection in most cases) damages the nutritive essences that supply the muscles and tendons [note: in Chinese traditional anatomy, the terms often refer to functions more than to isolated tissues. The tendons “aid in controlling movements.”]
<![if !supportLists]>2. <![endif]>Organ dysfunctions result in poor nutrition or in inhibited circulation, thus denying nutrition to the destination tissues.
<![if !supportLists]>3. <![endif]>Spiritual exhaustion reduces the communication between the mind and body, affecting sensation, movement, and mental clarity.
<![if !supportLists]>4. <![endif]>Adverse dietary factors can lead to weakness of muscles and laxness of tendons, and they can exacerbate deficiency of essence.
In the Huangdi Neijing Suwen, (9) the problem of muscular flaccidity receives an entire chapter. The basic ideas, largely retained since ancient times, have been elaborated recently in the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (10). The general problem is described as being due to a disorder affecting one of the five internal organ systems (zang). Thus, there are five types of wei (flaccidity) syndromes. Three of these might be of interest in regard to diseases such as MG, MS, and ALS.
Maiwei (vessel flaccidity, associated with the heart system) is described as muscular atrophy and debility of the lower limbs caused by pathologic heat of the heart, “empty” blood vessels, and malnutrition of the muscles of the lower limbs.
Rouwei (muscle flaccidity, associated with the spleen) has symptoms including sensory disturbance of the skin, and atrophy, flaccidity, and debility of the muscles. The syndrome is due to pathogenic heat and dampness invading the spleen with impairment of stomach yin.
Guwei (bone flaccidity, associated with the kidney) is caused by severe exhaustion of kidney yin and essence with accompanying deficiency fire that causes atrophy and flaccidity of the muscles of the lower limbs and weakness of the spine that makes it impossible for people to support themselves in an upright position.
The modern texts make some slight rearrangements of the categories, for example: liver/kidney weakness is presented as a single category, rather than two categories. A combination of the liver/kidney and spleen types is probably closest to depicting MS and other neuromuscular disorders that affect the lower limbs first.
The wei syndromes were described as being initiated by pathogenic heat (or damp-heat, the combination of two adverse influences) and display their symptoms of muscular weakening as a result of fluid and nutrient deficiency (e.g., lung fluid dryness, empty blood, stomach or kidney yin deficiency). The two other wei syndromes, affecting the tendons (liver; causing contracted ligaments) or the skin/hair (lung; causing cracked and brittle skin, paralysis of extremities), are also thought to be initiated by heat followed by impairment of fluids. The Neijing emphasizes that lack of nourishment in the channels (meridians) and in the muscles is the principal cause of the flaccidity. The Chinese concept of nourishment is broader than that identified in modern terminology as essential food components, because it includes several of the metabolic products of the food components (for example, hormones generated from precursors) and their entry into destination tissues (promoted by local microcirculation). To remedy the problem using acupuncture (the main therapy mentioned in the Neijing), one tonifies the deficiency by using the spring points (rong) on the meridians and promotes the flow of nutrients and energy through the meridians by treating the stream points (shu): “This fortifies the deficient, and restores order to what is rebellious.”
The traditional means of treating fluid impairment is to nourish blood and essence. There are several herbs classified as blood and essence tonics. In addition, qi tonics will help generate the essential fluids from foods. Connecting to the Western conception of the disease, the initiating infections for MS and for its exacerbations may involve a febrile syndrome; the imbalance that results might be destruction of fluids (the myelin sheath being a fluid fatty membrane; its quality is similar to that of essence; the brain and spinal cord are understood, by the concepts of traditional Chinese medicine, to be an extension of the kidney system, the storehouse of the essence).
An alternative traditional description of flaccidity syndrome—with similar conclusions—in presented in an article about treating one patient with MS (11). The doctors, Zhou and Lu, pointed out that ancient scholars believed the loss of sensations, one of the common MS symptoms, is related to the po (primitive instinct; one of the “souls” described in Chinese medicine). The po is governed by the spirit (shen) which subsists on the essence (jing). Quoting from the Huangdi Neijing Lingshu: “The po enters and exists with the essence...spiritual exhaustion scatters the soul and the po.” Pursuing this line, the authors state:
The kidney houses the essence; the brain is the mansion of the original spirit. Disorders of the spirit are usually related to a deficiency and damage of kidney essence which results in malnourishing of the brain. An insufficiency of original spirit in turn affects the function of the po. The manifestations of pain and soreness of the back, atrophic weakness of the legs, looseness of the lower passes (colon and bladder), and a sinking, thready, weak pulse confirm the diagnosis of kidney deficiency with damage to the essence. Poor memory and insomnia show an insufficiency of the sea of marrow (brain).
The kidney essence is the most refined of the body fluids recognized by traditional doctors. It is a substance that is, in part, present at birth (perhaps corresponding to the genetic material) and is, in part, replenished by refinement of nutritious food. Exposure to cold, excessive experience of fear, overindulgence in sexual activity, frustration from not being able to fulfill one’s wishes, over-tiredness from traveling in conditions of severe heat, consumption of too much salt, and physical injury to the internal organs are causes of kidney weakness cited in traditional literature. Other causes may include traumatic injury to the internal organs, effects of invasive surgery, chemical damage to the endocrine system, and chronic infections.
Dietary causes of flaccidity are usually described in terms of excessive intake. Aside from excessive consumption of salt damaging the kidney system, too much sour food is said to cause muscular laxity, and too much sweet food weakens the functions of the spleen, the organ system that is most essential to the nourishment of the muscles. Too much spicy food will cause further damage to depleted yin and essence. Therefore, diet is important to avoiding development of flaccidity syndromes or to counteract a disease which produces flaccidity.
BASIC HERBAL THERAPY FOR FLACCIDITY SYNDROME
The recommended traditional herb formula for treatment of the liver/kidney deficiency type wei syndrome is Hu Qian Wan. The Chinese name may be roughly translated as Pill of Tiger’s Walk; it refers to the well-controlled movements a tiger makes from a place of hiding while stalking a prey. The tiger also represents the yin: a tiger in hiding has great potential for expressing its power, and that hidden potential is yin. The herb formula has the therapeutic action of nourishing yin (Hu Qian Wan is sometimes described as the Pill of Hidden Tiger). As with other traditional treatments, the formula may be modified somewhat according to clinical presentation, especially at the initiation of therapy. For long-term applications, it is considered a well-balanced prescription.
Hu Qian Wan (25) is a formula devised by Zhu Danxi (1280–1358 A.D.) that was recorded in his book Dan Xi Xin Fa (Dan Xi’s Theories). Zhu Danxi was originally known as Zhu Zhenheng, and he lived in Danxi (Zhejiang Province). He became known as the renowned physician of Danxi, and was thus given the name Zhu Danxi thereafter. Zhu is known as leader of one of the four schools of Chinese medical disease etiology and treatment that evolved during the period of 1150–1350 A.D.; Zhu’s was the last of these schools (26) and one of the most influential in subsequent centuries. The four schools of thought were labeled according to the type of therapy that was predominantly advocated: cooling, purgation, spleen/stomach tonification, and yin nourishing. In modern practice, the latter two tonification-based schools remain dominant forces, joined by the late 19th century “school” of vitalizing blood circulation.
Zhu believed that the yin was always at risk for becoming deficient. Thus, in most chronic diseases, the aim of therapy should be to protect and nourish the yin. He devised several new formulations, many of them containing herbs that nourish the yin and cleanse deficiency fire (which is a type of yang agitation that can arise from yin deficiency and can cause worsening of yin deficiency). Zhu lived in southern China, where it was more likely that persons would suffer from the effects of heat and depletion of yin. He felt, however, that the main cause of yin deficiency was over-indulgence, including sexual excess, which could drain the kidney essence. He also pointed out that certain herbs could be damaging, especially for stroke, paralysis, nervous, and mental diseases: those containing what we now call heavy metals, and those which have properties of being spicy, fragrant, dry, hot, and stimulating (which could further weaken the cooling, moistening yin).
Hu Qian Wan is an expanded version of another of Danxi’s formulas, Da Bu Yin Wan (Great Yin Nourishing Pill), made with rehmannia and tortoise shell to nourish the yin, and phellodendron and anemarrhena to clear deficiency fire. To make Hu Qian Wan, one adds certain to this basic formula several ingredients to treat the specific manifestation for which the formula was intended: weakness of the lower back and knees, flaccidity of muscles and bones, and difficulty walking. The key additions are tiger’s bone (now replaced by other bones) and cynomorium. Tiger’s bone is said to treat weak and soft sinews and bones, and weakness of the knees and legs caused by deficiency of liver and kidney. Cynomorium has the same uses, and is also indicated for exhaustion of body fluids. These two herbs transform the basic treatment for yin deficiency into a treatment for flaccidity affecting the lower back and legs. One of the aims of the formula is to alleviate weakness of the tendons, which is deemed the main reason that there is difficulty in walking. Peony is added to the prescription to enhance the action of rehmannia in nourishing the liver, so as to benefit the liver’s associated tissues—the tendons. Citrus and dry ginger are added to aid the stomach in digesting the combination of rehmannia and cynomorium, which are quite rich and heavy in nature.
Hu Qian Wan is sometimes extended with tang-kuei, achyranthes, and mutton (a recommendation from a 17th century text), usually for cases of severe blood deficiency; other variations are prepared by adding yang tonics (in which case anemarrhena and phellodendron may be removed) or qi tonics. The usual preparation method is to combine the herbs ground up to powder and honey to make 9 gram pills (about 6 grams of the herbs per pill). It is taken one pill each time, 2–3 times daily (12–18 grams of the herbs per day).
The prescription that was initially given to the patient described by Zhou and Lu was a modification of another traditional formula used for flaccidity: Dihuang Yin Zi (Rehmannia Formula for Paralysis), a decoction containing rehmannia, cornus, schizandra, polygala, acorus, morinda, cistanche, aconite, cinnamon bark, hoelen, ophiopogon, and dendrobium. It nourishes the yin, but also revitalizes the yang. The modified formula was taken daily by the MS patient for more than three months. As a follow-up, Hu Qian Wan was administered in conjunction with the Dihuang Yin Zi decoction for one year. According to the doctors, The patient was eventually cured, thus confirming the benefit of kidney-nourishing decoctions and pills for MS.
Zhang Jianguo presented a case study (12) of treatment for chronic progressive spinal lateral sclerosis. As with the above analysis, the patient was diagnosed as suffering from deficiency of kidney and liver, insufficiency of blood and essence, and malnourishment of ligaments and bones. The treatment was a modification of the “Decoction of Flying Feet” (derived from Hu Qian Wan and Deer Antler Gelatin Pills) which includes the tonics: tortoise shell, rehmannia, tiger bone, eucommia, dipsacus, cuscuta, atractylodes, and licorice; later the prescription was modified by adding astragalus. The formula tonifies qi, yin, and yang. Treatment time was two months and gradual normalization of limb movements ensued.
A formula for treating wei syndrome was developed by Hukui Futei in Japan, based on Hu Qian Wan (27). It is called Wei Zheng Fang (Flaccidity Syndrome Formula) and is made with rehmannia, anemarrhena, phellodendron, peony, tang-kuei, achyranthes, atractylodes, astragalus, and eucommia. It has been used in Japan for treating disorders such as multiple myelitis, polio, and paralysis due to beriberi. Dr. Domei Yakazu reported good results in treating an MS patient using this formula for two and a half years.
In a review of traditional concepts of paralysis, Dr. Hong-yen Hsu (13) describes the syndrome of atrophy of the muscles. There are two sub-categories: weak and strong confirmation (constitution).
The weak confirmation is caused by yin weakness which impairs the flow of bodily fluids thereby preventing nutrients from reaching the muscles and bones...the strong confirmation may occur when the flow of the sunlight yang meridian becomes imbalanced by an attack of wet fever [damp-heat]. This will then impair the circulation to the limbs and cause the muscles to atrophy. A strong confirmation may also be induced by lung fever, wet sputum, or stagnant blood.
This explanation is based on the Neijing description.
To rectify the problem in individuals suffering from deficiency of liver and kidney, recommended formulas are Ginseng and Tang-kuei Ten Combination (Shichuan Dabu Tang) and Tiger’s Shinbone and Cynomorium Combination (Hu Qian Wan) for kidney and liver deficiency. For the strong confirmation, recommended formulas are San Miao Wan Modified (phellodendron, atractylodes, achyranthes, tang-kuei, stephania, tokoro, tortoise shell) for damp heat; Dao Tan Tang (with chih-shih, arisaema, pinellia, hoelen, citrus, ginger, and licorice) for sputum obstruction; and Tang-kuei Four Combination Modified (tang-kuei, cnidium, peony, rehmannia, persica, carthamus, zedoaria) for blood stagnation. According to traditional theory, a chronic disease that is caused primarily by deficiency syndrome tends to be insidious, while those caused by excess syndrome tend to show rapid progression.
Zheng Wentao and Mengrou undertook a general analysis of autoimmune disorders (14), with a detailed description of three autoimmune diseases: systemic lupus erythematosus, myasthenia gravis, and scleroderma. The basic approach might reflect on ways to evaluate the immunological aspect of MS. Citing traditional literature, the authors state:
With the stationing of genuine qi in the interior watching over the spirit, sickness is unable to intrude...the righteous qi is generated, transformed, and supplied by the essence of fluid and grain. When the spleen is flourishing, the external evil is unable to enter the body. The spleen is the material source of the body’s defense mechanism. Thus the flourishing or degeneration of the spleen function will reflect the strength or weakness of the body’s immune system.
The zhengqi (translated as genuine or righteous qi) is the guardian of the body’s health and the regulator of the immune system. Since qi tonic herbs are the basis of prescriptions for promoting zhengqi, these comments speak in support of the use of qi tonic therapies for autoimmune disorders. However, the authors continue: “Kidney yin and yang are the key factors in the regulation and balancing of yin, yang, qi, blood, and all the body’s immune mechanism. The visceral organs through their mutual dependence and restriction follow the rule: extreme damages; balance stabilizes; stabilization allows generation. Proper regulation of the normal immune response is thus achieved [through balance].” Such statements argue for the use of kidney (essence) nourishing herbs and following a balanced life style, in treating autoimmunity. “Qi in excess may inhibit or override, as stated in the Five Element Theory. The end result is the creation of an imbalance of the immune regulation, thus generating autoimmune diseases. According to the author’s observation, there may appear in the course of an autoimmune disease symptoms of deficiency, excess, or a combination of deficiency and excess.” Thus, while deficiency of qi and essence may form the basis of autoimmunity, at certain times in the development of autoimmune diseases, treatment of excess (accumulation) may be of importance.
Zhang and Meng state that: “According to TCM, the spleen governs the muscles, the four extremities, and the upper and lower eyelids. Therefore, the causative mechanism for MG is injury to the spleen and stomach and deficiency and degeneration of the central qi.” They recommended the use of large doses of Ginseng and Astragalus Combination, with doses of astragalus in the range of 30–90 grams. Further, “systemic MG is due to deficiency and injury of the spleen and stomach involving both the liver and kidney. This causes stasis of qi and blood, lack of transformation of fluid, obstruction of the meridians and luo vessels [meridians, jing, are generally distributed vertically and run through the deep tissues; connecting branches, luo, are distributed horizontally and superficially], and a decreased ability to move the ligaments and bones.” The authors state that favorable results have been obtained using large dosages of herbs. In addition to Ginseng and Astragalus Combination, they recommend Cinnamon and Aconite Combination, Pill of Right Restoration, and Fortified Pill of Buddha’s Warrior Attendant; these latter formulas all contain kidney tonic herbs and have a warming action that helps to overcome stagnation. For another case, characterized by “maximum depletion of the spleen and kidney, and indissoluble phlegm and turbidity, the recommended treatments were large dosages of Saussurea and Cardamon Combination to invigorate the spleen and clear away the dampness, and the kidney tonifying Rehmannia Eight Formula, in addition to the previously mentioned prescriptions. A specially-modified formula made with astragalus, codonopsis, atractylodes, aconite, cinnamon bark, rehmannia (raw), dioscorea, cornus, hoelen, lycium fruit, deer antler gelatin, and morinda was said to have produced dramatic effects after fifteen days of treatment (this is following treatment with the other prescriptions).
In the book The Treatment of Knotty Diseases with Chinese Acupuncture and Chinese Herbal Medicine (15) Shao Nianfang divides MG treatments into two basic categories: deficiency of spleen/kidney (weak category) and damp-heat (strong category). The deficiency type, especially with qi and yang deficiency, is said to be the most commonly-observed, clinically. Recommendations for treating deficient patients include use of a large dosage of astragalus and inclusion of chih-shih (which will clear phlegm-damp obstruction). For yang deficiency patients, the use of aconite is helpful and the amount should be large (30–60 grams, boiled for two hours).
In general, according to Shao, for MG of the deficiency syndrome type, one can use patent medicines such as Buzhong Yiqi Wan (Ginseng and Astragalus Combination), Fuzi Lizhong Wan (Aconite, Ginseng, and Ginger Combination), Hu Qian Wan, Jin Suo Gu Jing Wan (Lotus Stamen Formula), and Renshen Jianpi Wan (Ginseng Stomachic Pills), or a decoction made with ginseng, atractylodes, astragalus, platycodon, lycium fruit, aconite, cimicifuga, bupleurum, pueraria, tang-kuei, ma-huang, and licorice (Ginseng and Astragalus Combination modified). The dosage of the herbs is from 6 grams (licorice) to 60 grams (astragalus) each, with a total of about 200 grams for a one day dose. For yang deficiency patients, one can add cinnamon bark and deer antler; for yin deficiency patients, one can add Hu Qian Wan to the treatment.
For the damp-heat type, it is suggested to use the patent medicines, such as Longdan Xiegan Wan (Gentiana Combination) or Yangyin Qingfei Wan, or the decoction of atractylodes, phellodendron, scute, dioscorea, stephania, coix, peony, chaenomeles, glehnia, silkworm excrement (San Miao San modified). The dosage of herbs is from 10 grams (phellodendron, scute) to 30 grams (coix) with a total daily dose of about 150 grams.
Citing a case study of early onset of MG, Shao describes a young man with four limbs so flaccid and weak that he could not hold something in his hands, nor could he walk. He was diagnosed as suffering from deficiency of central qi following an acute illness with fever. He was given a decoction of atractylodes, pueraria, licorice, chih-shih, and tang-kuei. After fourteen days there was some improvement, and the formula was modified by adding lycium fruit, ho-shou-wu, aconite, and achyranthes. Treatment with this modified formula was followed for thirty days, after which there was significant reduction of symptoms. Finally, the patient was given Ginseng Stomachic Pills and Rehmannia Eight Formula daily. A follow-up two years later showed that recovery was complete.
Li Genghe (16) recommended that the treatment of MG follow the principle of tonifying the spleen and kidney. For spleen deficiency, the Ginseng and Astragalus Combination was used with optional additions of polygonatum, dioscorea, dolichos, and placenta. For spleen deficiency complicated by kidney yin deficiency, the Decoction of Left Restoration plus astragalus, atractylodes, and codonopsis was used (optional additions were ho-shou-wu, ophiopogon, peony, gelatin, and placenta). For spleen deficiency complicated by kidney yang deficiency, the Decoction of Right Restoration with eucommia replaced by deer antler, and with the addition of astragalus, codonopsis, and tang-kuei was used (optional additions were cynomorium, morinda, psoralea, eucommia, loranthus, and placenta). Li noted that common cold and bronchial infection (e.g., pneumonia) were predisposing factors for exacerbations. While steroids could be effective at that time, use of Chinese herbs was helpful in supporting the energy of the body and strengthening resistance; he recommended using ginseng, gecko, rehmannia, aquilaria, placenta, oyster shell, and licorice.
CLINICAL TRIALS IN CHINA
1. Multiple Sclerosis
The largest study (17) of Chinese medical treatment for MS was carried out by Lu Xi and Wang Yaohuo at the Departments of Neurology and Traditional Chinese Medicine in Fujian. Patients were first divided into four groups for differential treatment, two groups with deficiency-type syndrome and two groups with excess-type syndrome. The categories and treatments were:
<![if !supportLists]>1. <![endif]>Liver/kidney yin deficiency: raw and cooked rehmannia, lycium fruit, anemarrhena, salvia, peony, cornus, ligustrum, deer horn glue, tortoise plastron glue, achyranthes (chuanniuxi), tang-kuei, and licorice. This is a modification of the traditional Left Restoring Pill (Zuo Gui Wan) with the addition of anemarrhena, ligustrum, salvia, tang-kuei, and peony; it is somewhat similar to Hu Qian Wan. Each herb is used in a dosage of 10–12 grams per day, except licorice (5 grams).
<![if !supportLists]>2. <![endif]>Spleen-stomach weakness: astragalus, salvia, codonopsis, atractylodes, hoelen, pinellia, citrus, jujube, and licorice. This is a modification of the traditional Major Six Herbs Combination (Liu Junzi Tang) with astragalus and salvia added. Each herb is used in a dosage of 8–15 grams per day, except jujube (12 pieces) and licorice (4 grams).
<![if !supportLists]>3. <![endif]>Qi and blood stasis syndrome: astragalus, codonopsis, salvia, rehmannia (raw), peony (red and white), bupleurum, tang-kuei, scute, cnidium, pinellia, and licorice. This formula combines Minor Bupleurum Combination (Xiao Chaihu Tang) with three herbs for promoting blood circulation—salvia, peony (red and white), and cnidium—plus astragalus. Each herb is present in the amount of 9–15 grams per day, except licorice (4 grams).
<![if !supportLists]>4. <![endif]>Damp-heat syndrome: ching-hao, talc, peony, scute, bupleurum, bamboo, akebia, hoelen, chih-shih, pinellia, rhubarb, jujube. This formula is similar to treatments for febrile diseases described in previous centuries, such as the Ching-hao and Scute Combination (Hao Jin Qingtan Tang). Each herb is present in the amount of 8–12 grams, except jujube (12 pieces).
The formulas would be modified for certain presenting symptoms. For example, for urinary incontinence, add cuscuta, alpinia, and rose fruit; for constipation, add ho-shou-wu, persica, cistanche, and rhubarb; for mental fogginess, add schizandra; for abdominal distention, add magnolia bark and chih-shih; for muscular atrophy, add tang-kuei, gelatin, and dipsacus.
The decoctions were consumed as a cooling drink (rather than hot; because many MS patients have an aversion to heat), once per day. Anti-inflammatory Western drugs (dexamethasone or prednisone) were given during acute active periods. Thirty-five patients were treated and except for three that discontinued treatment within the first ten days, some improvement was found. Two cases were deemed basically cured after taking 45 and 68 doses; 15 were markedly improved and another 15 somewhat improved, most of them taking 20–40 doses. Eleven of the patients had tried corticosteroids unsuccessfully before switching to the traditional herb combinations; of these, seven were markedly improved, three improved, and only one failed to respond.
These researchers followed up their work with an attempt to prevent exacerbations (18). They prescribed Ping Fu Tang (Pacify Relapse Decoction) to 30 patients over a period of 3–13 years (average of 6 years). The formula contained astragalus, codonopsis, hoelen, atractylodes, pinellia, licorice, jujube, bupleurum, scute, tortoise shell, ligustrum, tang-kuei, peony, ophiopogon, rehmannia, lycium, and anemarrhena. The prescription basically has the effect of tonifying qi, yin, and blood, and clearing deficiency heat. It can be seen that this prescription is derived from the first two formulas listed in the previous article for treatment of multiple sclerosis, based on deficiencies of liver, kidney, and spleen (it also has some herbs of Minor Bupleurum Combination, as mentioned below). The preventive therapy was basically a tonic formula. It was prescribed in the form of a decoction, taken in 2–3 daily doses, using 8–15 grams of each herb (except smaller amounts of licorice and jujube). According to the researchers, relapses were prevented except for two patients who each experienced only one minor exacerbation, each event following a viral infection (common cold). A control group of MS patients not treated by this remedy was monitored for three years: they suffered from exacerbations at the rate of 1–4 times per year.
Ping Fu Tang included rehmannia, tortoise shell, peony, and anemarrhena, ingredients of Hu Qian Wan, which have the functions of nourishing yin and blood and cleansing deficiency fire. In addition, they added ligustrum, lycium fruit, and ophiopogon to nourish yin. A strategy for nourishing blood and essence is to tonify the qi so that more nutrients are obtained from the food. The formula included astragalus, codonopsis, hoelen, atractylodes, licorice, and jujube towards this end (these herbs also enhance immune functions to aid resistance to infections that induce exacerbations). Since the point of the treatment was not to rectify flaccidity, but rather to prevent flaccidity by preventing exacerbations, the herbs for treating flaccidity in the legs, such as tiger bone and cynomorium found in Hu Qian Wan were not included. Also, as the patients are being treated continuously with the yin-nourishing tonics, it is not necessary to strongly inhibit deficiency fire, so phellodendron is not essential to the prescription (anemarrhena, unlike phellodendron, has the secondary property of being a yin tonic). Thus, the treatment largely reflects the principles of Zhu Danxi in relation to understanding the cause of a flaccidity syndrome. The doctors explained that part of their thinking in developing the formula was based on the current understanding of autoimmunity, which explains the presence of so many qi tonics and the herbs of Minor Bupleurum Combination (Xiao Chaihu Tang), such as pinellia, bupleurum, and scute, which is believed to be helpful in chronic inflammatory diseases.
If a T-cell attack against myelin sheaths is initiated by influenza, common cold, sinusitis, or other infections, ability to prevent such infections or halt their progress would be one obvious key step in preventing damage due to the usual sequence of events in an exacerbation. Protection from transmissible viral infections, such as staying away from those who are currently suffering from the infection, is one method of prevention. Enhancing the immune system functions with tonic herbs is another method. Many Westerners are led to believe, by poorly written articles on immune disorders, that enhancing immune system vigilance would worsen any autoimmune disease; however, this would only be a potential problem during an exacerbation; even then, other components of the immune system that help to shut-down the autoimmune attack may be coaxed into activity with proper immune-regulating herbal treatment strategies.
2. Amyotrophic Lateral Sclerosis and Progressive Spinal Muscular Atrophy
Case studies of ALS were reported by Lin Tongguo (19). In one case, the primary formula combined tonic herbs: astragalus, tang-kuei, peony, rehmannia, aconite, cinnamon bark, and lycium fruit, with several herbs used to promote circulation of blood and relieve spasms (the spasms being a significant problem in many cases of ALS): centipede, scorpion, persica, carthamus, morus twig, and clematis. These herbs were made as a decoction taken in divided doses three times daily for several days. In addition, a small amount of powder made from strychnos and musk (0.25 grams of each, three times daily) was given. As follow-up, the decoction formula was modified (cnidium, platycodon, chih-ko, tiger bone, deer antler, and zaocys were added; morus twig and clematis were deleted) and made into pills instead of decoction, to be taken 18 grams per day—the musk and strychnos powders were included in the pills. The pills were taken for two years until the disease was resolved. A follow-up after three years with no further medication showed that the disease had remitted. A similar approach was used with a second patient who consumed a decoction made with astragalus, atractylodes, cinnamon twig, tang-kuei, persica, carthamus, centipede, eupolyphaga, fenugreek, aconite (chuanwu), licorice, and zaocys. After using this decoction for several days, the pill described above was used for long-term medication and a clinical cure was obtained, with a follow-up after five years confirming the satisfactory result.
The third case emphasized treatment of yin deficiency fire, using a decoction with phellodendron, raw rehmannia, moutan, alisma, anemarrhena, hoelen, stephania, coix, chin-chiu, dipsacus, achyranthes, centipede, and scorpion. This decoction was given for more than two months and then modified, taking out stephania, coix, and chin-chiu, and adding dipsacus, deer antler, epimedium, tang-kuei, cnidium, and carthamus. This formula was then used for more than three months. Finally, the above-mentioned pill was again used for long-term therapy, and a cure was obtained, with no relapse by the end of two years without the medication.
In a report by Kang Yanghuo of two cases of progressive spinal myoatrophy (20) the main prescriptions given were variations of Shengji Yisui Tang (Decoction for Generating Muscles and Benefiting Marrow). One such prescription contained tang-kuei, lycium fruit, atractylodes, ophiopogon, tortoise shell, achyranthes, phellodendron, alisma, chaenomeles, and licorice for a yin deficiency case and deer antler, eucommia, atractylodes, astragalus, psoralea, malt, crataegus, pinellia, codonopsis, sinapis, hoelen, alisma, chaenomeles, achyranthes, and cinnamon twig for a yang deficiency case with weak digestion and phlegm accumulation. Treatment time was six months and included acupuncture and massage therapy. Long-term follow-up showed persisting benefits of the treatment, with normal nerve conduction and physical activities.
In a study (21) of 15 patients with progressive ALS, a significantly expanded version of Hu Qian Wan was employed. This contained astragalus, epimedium, deer antler, syngnathus, sea horse, ginseng, tortoise shell glue, tang-kuei, peony, rehmannia, lycium fruit, eucommia, dipsacus, cuscuta, cynamorium, atractylodes, coix, citrus, achyranthes, chaenomeles, chin-chiu, agkistrodon, tiger bone, psoralea, anemarrhena, phellodendron, cinnamon twig, chiang-huo, tu-huo, and siler. The formula was based on the traditional prescription Jian Bu Hu Qian Wan (Step Reinforcing Tiger’s Walk Pill). The pills were taken in a dosage of 3–9 grams at a time, 2–3 times per day depending on the person’s constitution and severity of the disease, but were not to be used by patients showing yin deficiency fire syndrome. Two of the patients were said to be cured and five improved. The pills were to be used on a regular basis over a period of several years.
Strychnos is sometimes mentioned as part of ALS treatments. A muscle-invigorating combination known as Mobilizing Powder may produce temporary alleviation of flaccidity. The combination includes strychnos, musk, and centipede. Strychnos in small doses tones the muscles and in large doses paralyzes them. It is used in the treatment of other autoimmune disorders, including MG and rheumatoid arthritis. Unfortunately, this herb cannot enter into Western treatments for autoimmune diseases because of concerns over the toxicity of strychnine, one of the main active components.
A large scale study of progressive spinal muscular atrophy (80 cases) and ALS (30 cases) was described by Huo Yintang (22). The primary formula used for treatment was Yisui Tang, made with codonopsis, atractylodes, astragalus, rehmannia, psoralea, dipsacus, cuscuta, achyranthes, cibotium, tang-kuei, peony, millettia, tortoise shell, deer antler gelatin (each herb 9–15 grams in decoction), with 5 grams each phellodendron, and anemarrhena. This formula is a substantial modification of Hu Qian Wan, utilizing several yang tonic herbs to replace the tiger’s bone of the ancient prescription. According to the report, 59 cases were considered cured (symptoms alleviated, muscles regenerated, and muscular function restored), 18 markedly improved, 25 improved, and 8 showed no improvement.
3. Myasthenia Gravis
Yakazu reported (23) that formulas containing ma-huang, such as Pueraria Combination (Gegen Tang) and Minor Blue Dragon Combination (Xiao Qinglong Tang), were repeatedly found to improve symptoms, at least for short-term treatment, in patients with MG. He attributes this effect to the active component ephedrine, which was previously reported to be effective for myasthenia by Dr. Nabi Ryoken in his book The Revised Practical Medical Service. Ma-huang is traditionally used in the treatment of muscular aching and ephedrine is known to promote circulation through the striated muscles. Yakazu also recommended the use of peony and licorice, stating that this combination “adjusts the tenseness” of the muscles. Licorice also has cortisone-like action. These two herbs are frequently used to relieve muscle spasms, perhaps with better effect in patients suffering from deficiency syndromes. In like manner, he thought that pueraria, traditionally used to relax tense muscles in the neck and shoulders, might help to treat flaccidity of these same muscles when given to patients with MG. In the case study of early MG presented by Shao Nianfang, pueraria was included.
In a study (24) of treatments for MG reported by Qiu Chengling, eight patients received capsules containing strychnos (0.2 grams per capsule), gradually increasing the daily dosage to reach seven capsules each time, three times daily. In addition, the patients were treated with decoctions according to the classification of underlying syndrome. For those with spleen deficiency, Ginseng and Astragalus Combination (Buzhong Yiqi Tang) plus epimedium was given. For spleen and kidney deficiency, a decoction of astragalus, epimedium, tang-kuei, atractylodes, codonopsis, rehmannia, dioscorea, curculigo, anemarrhena, and morinda was given; in cases of more severe yang deficiency and cold, cinnamon twig, aconite, and deer antler glue were added. As a result of these therapies, 5 of the 8 patients noted significant improvements.
Li Genghe (16) reported on the cumulative results of treating 250 patients over a period of five years. He claimed that long-term ingestion of herbs that tonify the spleen and kidney could lead to a clinical cure in nearly half the patients. The duration of therapy necessary was 3–5 months for the eye-muscle type (which was easier to cure) and 6–8 months for the general type. Domei Yakazu believed that those not cured by tonification therapies might benefit from the ma-huang formulas.
SUMMARY OF CLINICAL TRIALS
Formal clinical trials involving several patients rather than individual case studies began in 1975 and have included only few hundred patients. Since the Western medical knowledge of the diseases was limited and advanced equipment often not available, the early research was based almost entirely on traditional analysis of treating flaccidity syndrome and guesses as to the treatment of autoimmunity. The claimed positive results, ranging from a high proportion of persons with marked improvements to a substantial number of cases declared cured, were often a consequence of treating patients with different formulas according to diagnostic categories and with changes in prescription during the first few weeks or months of therapy. Tonification of spleen, kidney, and liver are the prominent methods of therapy. It was common to combine decoctions and pills, and to use pills as long-term therapy, which sometimes lasted for two years. In some cases, acupuncture, Western medicine, and other therapies were said to be used: undoubtedly, in most trials the patients received the therapeutic interventions that the physicians felt were necessary within the limitations of what could be offered.
AMERICAN PATIENTS WITH MS
According to clinicians working at the ITM clinic, diagnosis of American patients suffering from multiple sclerosis reveals the presence of yin deficiency, but relatively little experience of the yin deficiency fire. Rather, these individuals have a greater tendency to display signs of weakness of the stomach functions and some deficiency of kidney yang. This apparent difference between these findings compared to the explanation of leg flaccidity by Zhu Danxi may be related to several factors. For example, MS is more common in the colder northern regions, where yang deficiency is more prevalent, while Zhu observed patients in southern regions where yang deficiency is less common. The cause of the disease, though complex, appears to be infectious agents and autoimmune process, rather than debilitating life style (though life style factors could contribute to disease initiation and progression), which was the dominant concern in Zhu’s time. The Western diet may help to limit deficiency fire syndrome, but might worsen stomach problems. Malabsorption in MS patients has been noted for fats, vitamin B12, and d-xylose, and low HCl levels may be responsible for limited digestion of meats (28). In China, low HCl levels were noted in patients with MG (29), and the lowest levels were closely associated with refractoriness to treatment.
DIETARY AND NUTRITIONAL CONSIDERATIONS: EAST AND WEST
Providing adequate nutrition is considered critical in the traditional description of flaccidity syndrome. To treat essence deficiency, Chinese doctors recommend that certain foods be eaten, including duck, abalone, pig kidney, liver, lotus seeds, rose hips, and walnuts (29).
As mentioned earlier, avoiding certain foods is also a consideration of traditional Chinese thinking. Black pepper is to be avoided in cases of muscular weakness. Recently it was shown that a component of pepper inhibits convulsions and it may have a mild inhibitory action on muscular contraction. Cinnamon, with its key component cinnamaldehyde, should be avoided in persons with MS, as the aldehydes may already inhibit nerve transmission. These two herbs are warm and spicy in nature, and would be limited by the prevailing Chinese theory that spicy herbs can worsen yin deficiency. Cinnamon is used in some treatments of flaccidity, but might be more suitably replaced by other herbs that accomplish the same therapeutic goal, such as cynomorium, morinda, or dry ginger.
Ingestion of essential fatty acids and EPA from fish oil appears to be of some aid in treating autoimmunity in general (4). Fatty acids and fish oil supplementation may correspond to tonifying the yin, based on Chinese dietary recommendations. Avoidance of zinc or use of zinc-chelating agents also reduces some autoimmune responses (1), though zinc deficiency can lead to easier experience of viral infections that activate MS attacks.
Tortoise shell (rich in gelatin) and deer antler gelatin are included in several prescriptions for treatment of flaccidity of the legs. Glycine is a major component of gelatin, which is classified by Chinese doctors as a blood and yin tonic. The amino acid glycine has been recommended for persons with MS since it counteracts aldehyde accumulation and has antispasmodic properties (daily dosage is about 3 grams per day).
Since 1950, it has been proposed that a diet low in saturated fats may benefit some MS patients, and a clinic at Oregon Health Sciences University, formerly run by Dr. Roy Swank, professor of neurology, has specialized in this area of treatment for several years. He recommends no more than 10 grams of saturated fat per day, which basically yields a vegetarian diet supplemented by fish (three or more times per week; the fish oils are considered beneficial as are polyunsaturated oils). Many persons find this diet to strict to be practical. High levels of polyunsaturated oils may increase oxidative stress, and so should be countered by taking antioxidants.
Vitamin B12 is found primarily in animal foods and is also present in walnuts. This vitamin may contribute some of the essence-tonifying properties of foods recommended by Chinese doctors. A number of reports of vitamin B12 deficiency in some MS patients has led to the use of this vitamin in treatment of those who are found to have low B12 either in the serum or the cerebrospinal fluid. Low vitamin B12 levels were found to be associated with earlier onset of disease symptoms and were reduced by corticosteroid administration (38). However, it may be the unsaturated B12 binding capacity that is more often low, even if total B12 levels are normal (39). When patients with chronic progressive MS were given 6 mg of oral B12 every day for six months, there were improvements in visual and brainstem auditory evoked potentials. Since MS patients are likely to have poor B12 uptake, B12 is often given by injection, with doses up to 1 mg each time.
STEPS TO TAKE IN TREATMENT
To follow Chinese medical theories and experience in treating MS, MG, ALS, and other flaccidity syndromes, one would undertake the following:
<![if !supportLists]>1. <![endif]>Eat a diet that is nourishing to the spleen, kidney, and liver, especially with essence-tonifying foods (this would include various beans and seeds, meats, seafoods, and mildly astringent fruits). Avoid excessive amounts of sour, spicy, and salty foods. Consider use of nutritional supplements with selenium, calcium, vitamin B12, antioxidants, and essential fatty acids. Also consume gelatin or a glycine supplement (3 grams per day), especially in cases where muscle spasms occur.
<![if !supportLists]>2. <![endif]>Consume herb formulas that match the particular manifestation of symptoms and signs recognized by traditional medical theory. Deficiency is to be nourished; obstruction, overcome; and excess, drained. In cases of deficiency syndrome (which appear to be the most common), consider the use of substantial doses of tonic herbs, and give special attention to the need for yin or yang tonic agents. Anti-inflammatory drugs may help limit the damage to myelin if their use is initiated early in an attack, but they may have little benefit the rest of the time. Immune-regulating drugs, such as betaseron, can be tried if the herb therapies fail to produce adequate regulation.
<![if !supportLists]>3. <![endif]>Avoid viral infections (and other infections) by minimizing exposure to infected persons and to potentially harmful environmental conditions (e.g., chill). Take an antiviral herb combination when an acute viral attack is suspected. Treat all infections promptly, whether using herbs or drugs.
<![if !supportLists]>4. <![endif]>Utilize practices that evoke spiritual rejuvenation. Traditional Chinese exercises, such as Qi Gong and Tai Ji Quan may be helpful in strengthening the normal qi, benefiting the kidney, and calming the spirit. They also improve muscle control and balance.
<![if !supportLists]>5. <![endif]>Use acupuncture to invigorate circulation of qi and blood in the limbs and to restore nervous system connections. Scalp acupuncture has proven helpful in treating disorders of the central nervous system, including MS (40). Dr. Chen Zelin and Chen Meifang in the book A Comprehensive Guide To Chinese Herb Medicine (41), recommend the following body points for flaccidity syndrome (3–4 points should be selected for each daily or every other day treatment for 10 days):
Flaccidity of the arms: GV 4, 12; LI 11, 15; SI 4, 9; TB 5, BL 11.
Flaccidity of the legs: GV 2, 3; BL 57, 60; GB 30, 31, 34, 39; SP 6, 9; ST 36
6. New Western medical approaches should also be considered. Recent research suggests that it may be possible to selectively inhibit the autoimmune attack against myelin using a T-cell receptor (TCR) peptide drug that does not defeat the entire immune system but rather blocks the attack by matching the basic protein on myelin that binds the T-cells. Initial tests in animals with experimental allergic encephalymyelitis, a model for MS, showed good results, and clinical tests in a small number of patients have yielded promising outcomes (42). If successful, the same basic method, using a different peptide, might be useful for other autoimmune disorders, such as MG. The drastic inhibition of immune functions, which is possible with currently-available drugs, such as high dose corticosteroids or cyclosporin, should only be considered as an emergency measure. Chinese herb drugs that inhibit acetylcholinesterase, such as huperzine A and fordine, have been used with some success in treating myasthenia gravis in China.
7. Parents who have MS should take special care to make sure that their children get adequate nutrition, have vaccinations against common preventable diseases, and take steps to avoid excessive exposure to infectious and parasitic agents. Their children have an increased risk of disease due to genetic factors, so that extra care may be needed to avoid development of the disease.
Several Chinese language articles were translated by Fu Kezhi in Harbin; Deng Zhongjia, through literature research, provided an article on Ping Fu Tang, a portion of that article was translated by Heiner Fruehauf, Ph.D., L.Ac. in Portland; Dr. Fruehauf also provided translations of articles on ALS and progressive spinal muscular atrophy. Barry Levine, L.Ac. in Norwood, Massachusetts, provided several abstracts and articles on the Western medical analysis of MS and its treatment. The MS Foundation in Fort Lauderdale, Florida provided funding for treatments of MS patients at the ITM clinic.
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<![if !supportLists]>6. <![endif]>Gianani R and Sarvetnick N, Viruses, cytokines, antigens, and autoimmunity, Proceedings National Academy of Sciences USA 1996; 93: 2257–2259.
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<![if !supportLists]>8. <![endif]>Sommer N, et al., The antidepressant rolipram suppresses cytokine production and prevents autoimmune encephalomyelitis, Nature Medicine 1995; 1(3): 244–248.
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