Combination therapy with tsumyakushigyakuto (tong-mai-si-ni-tang) and sekiganryo (chi-wan-liao) and the sequence of medication

We report two cases of severe general fatigue successfully treated with a combination of tsumyakushigyakuto and sekiganryo. Case 1 was a 39-year-old female who was diagnosed with chronic fatigue syndrome. In March, she came to our hospital and was treated with tsumyakushigyakuto, but her fatigue did not improve. She was admitted to our hospital in April, complaining of severe subjective/objective coldness. As thermotherapy with electrothermo-acupuncture using a curved heating plate originated by Ogura reduced her fatigue, we suspected she had severe cold syndrome and administered sekiganryo in a daily 06.00 half-day dose (150ml). Her fatigue and coldness decreased markedly. We administered tsumyakushigyakuto at 06.00 and 15.00, and sekiganryo at 10.00 and 20.00 hours. Her fatigue worsened in the morning, so we administered sekiganryo earlier, with the first dose at 06.00, and the fatigue decreased. Case 2 was a 43-year-old male diagnosed with depression. His fatigue worsened and he was admitted to our hospital in April. Because his pulse was very weak and he quickly became fatigued, we administered tsumyakushigyakuto. By the following morning his fatigue had slightly improved. He could tolerate electrothermo-acupuncture for at least 30 minutes. We suspected cold syndrome and administered combination therapy of tsumyakushigyakuto and sekiganryo. After this, his morning fatigue improved considerably. Our two cases had indications for both tsumyakushigyakuto and sekiganryo. Severe cold syndrome, which could not be reduced with tsumyakushigyakuto alone, was effectively treated with sekiganryo. Our cases indicate that it is effective to administer sekiganryo before tsumyakushigyakuto.