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Chinese Medicine Times

Chronic Fatigue Syndrome

by Giovanni Maciocia

From a western perspective chronic fatigue syndrome (CFS), which used to be called M.E. (myalgic encephalomyelitis), is a relatively new disease and it is unclear what the causative agent might be. Indeed, in Western medicine there is no general agreement that it is a separate disease at all. Even its name is not generally agreed upon as it is variously called ‘post-viral syndrome’, ‘chronic post-viral fatigue syndrome’, ‘chronic mononucleosis, ‘chronic Epstein-Barr virus disease’, and, especially in the USA, ‘chronic fatigue immune deficiency syndrome

Western medicine pathophysiology

The reason there is no general agreement on the nature and causative agent of this disease is that there is no conclusive test which is specific to CFS. There is no blood test that would conclusively prove a patient suffers from CFS in the same way there is for, say, mononucleosis. Current research, however, does show that CFS might be caused by an enterovirus and specifically, the Coxsackie sub-group of enteroviruses. In the USA, research seems to be oriented towards the Epstein-Barr virus (the one that causes glandular fever or mononucleosis) as a cause of CFS Enteroviruses entry via the mouth causing sore throat and enlarged glands. Immune response can be compromised by physical or mental stress, immunosuppressive drugs, pregnancy, malnutrition or surgery. If primary immune response fails, enteroviruses can pass to lungs or large intestine producing a chest infection of gastroenteritis. Inside the intestines, the enteroviruses remain and multiply forming a reservoir of infection. From here, they can spread via the blood stream to other tissues including nerve, muscle and endocrine glands. Enteroviruses have a particular tropism for muscles and nervous tissue: this explains the clinical manifestations of CFS, i.e. the muscle ache and changes in brain function. Chronic Fatigue Syndrome patients recognize the virus and respond to it but without eliminating it for extended periods. As we shall see, from the Chinese perspective, this inability of the patient to rid themselves of the virus is due to a deficiency of the body’s Qi.

Chinese medicine pathophysiology

Although modern Chinese books do not discuss CFS, Chinese medical books have, since very early times, described the cause, diagnosis and treatment of conditions similar to Chronic Fatigue Syndrome. For example, the clinical manifestations of Li Dong Yuan’s theory of Yin Fire deriving from a deficiency of the Original Qi resemble quite accurately a situation of CFS.

The five main conditions with which CFS can manifest are:

• Residual pathogenic factor

• Latent Heat

• Lesser Yang pattern

• Yin Fire

• Deficiency

a) Residual pathogenic factor

One of the main conditions leading to post-viral fatigue is that of “residual pathogenic factor”. If external Wind invades the body and is not cleared properly, or if the person fails to rest during an acute invasion of Wind, the pathogenic factor may remain in the Interior (in the case of CFS usually as Dampness).

After an invasion of a pathogenic factor, the pathological development can have three possible outcomes:

• the pathogenic factor may be expelled completely

• it may become interior

• it may appear to have been expelled, but a residual pathogenic factor has been formed

The residual pathogenic factor can be formed however, after an exterior pathogenic factor has become interior. Therefore, a residual pathogenic factor may be formed at the exterior or interior stage; from the perspective of the Four Levels, a residual pathogenic factor may be formed at the Wei or Qi level.

A residual pathogenic factor is simply a left-over pathological product when the patient appears to recover after an acute invasion of an exterior agent but the illness persists. Once formed in the Interior, a residual pathogenic factor continues to produce symptoms and signs or, it predisposes the person to further invasions of exterior pathogenic factors because it obstructs the proper diffusing and descending of Lung-Qi and the ascending and descending of Spleen-Qi and Stomach-Qi. It will also tend to weaken Qi and/or Yin, establishing a vicious circle of pathogenic factor and deficiency.

Residual pathogenic factors frequently manifest with Dampness and/or Phlegm. This occurs because external Wind and its resulting residual pathogenic factor disrupt the ascending of Spleen-Qi cannot descend, turbid fluids are not transformed, and because Spleen-Qi cannot ascend, the clear fluids cannot be transformed; this leads to the formation of Dampness and/or Phlegm. Also, heat burns the body fluids which can then condense into Dampness or Phlegm. Once formed, Dampness and/or Phlegm are rather self-perpetuating. In fact, Dampness and Phlegm impair the Spleen’s transformation and transportation which in itself leads to more Dampness of Phlegm being formed, thus establishing a another vicious circle.

Five main causes that favour the formation of a residual pathogenic factor:

• weak constitution

• exposure to cold, dampness or wind too soon after an invasion of external Wind

• irregular diet

• not taking care during an acute illness

• antibiotics

In the case of CFS, the residual pathogenic factor is nearly always Dampness (with or without Heat) and is typically in three locations.

• head (causing poor memory and concentration)

• stomach and Spleen (causing digestive problems)

• muscles (causing muscle ache, fatigue and heaviness)

b) Latent heat

Symptoms of CFS, appearing without an acute infection can be explained as a manifestation of Latent Heat. The concept of Latent Heat is very ancient and originally, it was used to explain the manifestations of acute Heat as a transformation of Cold. The Simple Questions in chapter 3 says: ‘if Cold enters the body in wintertime, it comes out as Heat in springtime.’ Wang Shu He says: ‘In Winter Cold attacks causing Shang Han disease; if a person does not fall ill, the Cold hides under the skin and in springtime it changes into Heat’, and Ye Tian Shi says: ‘Warm disease in Spring is due in every case to pathogenic factor lurking in Winter’. This means that under certain circumstances, a pathogenic factor (which may be Wind-Cold or Wind-Heat) can enter the body without causing immediate symptoms. It then incubates inside the body for some time, turning into Heat which later emerges towards the Exterior causing a person to feel suddenly very tired with weary limbs, slightly thirsty, hot and irritable. He or she would not sleep well and the urine would be dark. At this time the pulse feels fine and slightly rapid and the tongue is red. This condition is called Latent Heat or Spring Heat, although it can occur in any season and not just in springtime.

Clinical manifestations

• weary limbs

• irritability

• insomnia

• slight thirst

• slight feeling of heat

• lassitude with sudden onset

• dark urine

• red tongue

• rapid-fine pulse

Besides causing the above symptoms and signs, Latent Heat will also tend to injure Qi and/or Yin, thus establishing a cycle of Heat and deficiency. Latent Heat occurs when an individual suffers an invasion of exterior Wind without developing immediate symptoms and the pathogenic factor goes into the interior where it turns into Heat and comes out months later. The underlying reason for this is usually a Kidney deficiency. If the body condition and the Kidneys are relatively good, a person will develop symptoms at the time of invasion of external Wind. This is a healthy reaction. If the Kidneys are weakened by overwork and excessive sexual activity, the body’s Qi is too weak even to respond to the invading external Wind. This causes the Wind to penetrate into the Interior without the person developing exterior symptoms. Once in the Interior, it incubates and turns into Heat to come out some months later.

Ancient doctors believed that if the Essence is properly guarded and not dissipated, pathogenic factors will not enter the body and Latent Heat will not develop. The Simple Questions in chapter 4 says: ‘The Essence is the root of the body, if it is guarded and stored; Latent Heat will not appear in springtime’. It also says: ‘In Winter, Cold attacks; in Spring, Heat attacks’.

c) Lesser Yang pattern

Exterior Wind-Heat (or Wind-Cold) can sometimes lodge itself in an energetic niche which is in between the Interior and Exterior (called Half-Exterior/Half-Interior in Chinese). In the scheme of the 6 Stages patterns and specifically of the three Yang stages, the Greater Yang (Tai Yang) stage is the most exterior, the Bright Yang (Yang Ming) the most interior and the Lesser Yang (Shao Yang) the “hinge” between the two. Sometimes, exterior Wind invades the body through the Greater Yang stage and then lodges itself in the Lesser Yang stage: when this happens, the pathogenic factor is “trapped” between the Greater Yang and Bright Yang stages: it somehow “bounces” back and forth between the Exterior (Greater Yang) and the Interior (Bright Yang). When it bounces towards the Greater Yang, the patient experiences aversion to cold; when it bounces back towards the Bright Yang, the patient feels hot (subjectively hot).

Clinical manifestations

• feeling hot and cold in alternation

• fullness of the hypochondrial region

• poor appetite

• irritability

• dry throat

• nausea

• bitter taste

• blurred vision

• white-sticky tongue coating on one side only

• wiry pulse

d) Yin fire

The concept of Yin Fire was introduced by Li Dong Yuan in his book Discussion of Stomach and Spleen (Pi Wei Lun, 1246). Dr Li says that as a result of improper diet and overwork, the Original Qi (Yuan Qi) becomes weak in the Lower Burner and the Stomach and Spleen are weakened in the Middle Burner. This causes the patient to feel tired and often cold. When the patient is also subject to emotional stress, the Ministerial Fire is stirred, it becomes pathological and it leaves its place of ‘concealment” in the lower Dan Tian

As the Ministerial Fire and the Original Qi reside in the same place in the lower Dan Tian, the pathological Ministerial fire displaces and weakens the Original Qi even more. Dr Li said that pathological Ministerial Fire becomes a ‘thief’ of the Original Qi. The arousal of the pathological Ministerial fire upwards causes some Heat and mouth ulcers. This he called ‘Yin Fire’. Yin Fire is neither Full Heat nor Empty Heat but simply a different kind of Heat that derives from a deficiency of the Original Qi and of the Stomach and Spleen. Yin Fire is not treated by clearing Heat or draining Fire but by tonifying the Original Qi and gently clearing Heat upwards.

The pathology of Yin Fire is further complicated by Dampness and by a pathology of the Middle Burner as well. When the Spleen is deficient, Dampness is formed and this infuses down to the Lower Burner. Here it ‘swamps’ the Original Qi and the Ministerial Fire displacing the latter from the place (the Lower Burner) where it should be concealed. The Middle Burner has Dampness too; Spleen-Qi (or even Spleen-Yang) is deficient and fails to rise. For this reason, Bu Zhong Yi Qi Tang Tonifying the Centre and Benefiting Qi Decoction is used to raise Spleen-Qi and warm Spleen-Yang so that Dampness no longer infuses downwards to the Lower Burner. When the Lower Burner is opened and unblocked from Dampness, the Ministerial Fire will return to its place of concealment in the Lower Burner, thus eliminating the symptoms of Yin Fire.

Bu Zhong Yi Qi Tang eliminates Yin Fire by tonifying the Original Qi with Ren Shen Radix Ginseng and by lightly clearing Heat upwards with Chai Hu Radix Bupleuri and Sheng Ma Rhizoma Cimicifugae. The remedy Tonifying Qi and Ease the Muscles is a variation of Bu Zhong Yi Qi Tang.

Clinical manifestations

• feeling of heat in the face

• red face

• mouth ulcers

• occasionally a low-grade fever

• dizziness

• weak voice

• depression

• muscle weakness

• exhaustion

• feeling cold in general

• loose stools

• cold feet

• spontaneous sweating

• shortness of breath

• pale tongue

• weak pulse

e) Deficiency

In addition to the above four factors, in CFS there is always an underlying deficiency of the body’s Qi which favours the formation of Latent Heat, a residual pathogenic factor, or of Yin Fire. The deficiency may be of Qi, Yang, Blood or Yin although a deficiency of Qi is the most common. The organs involved are mainly the Spleen, Lungs, Liver and Kidney; of these, the Spleen is the one most commonly involved. In the development of Latent Heat and Yin Fire, a deficiency of the Kidney is a particularly important. As we have seen above, in Latent Heat a person is subject to an invasion of Wind without developing acute symptoms. The pathogenic factor penetrates into the Interior and it lurks inside to emerge later as Latent Heat. The reason for this pathology is primarily a deficiency of the Kidney.

I personally consider the essential manifestations of true Chronic Fatigue Syndrome to be in four main groups:

• pronounced muscle fatigue and ache

• poor memory and concentration

• exhaustion

• persisting, intermittent, general flu-like feeling

Summary of TCM aetiologies

• overwork

• irregular diet

• excessive sexual activity (in men)

• emotional stress

• excessive physical work and sport

• antibiotics (in the case of residual pathogenic factor)

• immunizations (in the case of Latent Heat)

Clinical note

In order to distinguish full from empty conditions of CFS, I attach great importance to the tongue and pulse.

If the tongue has a thick coating and the pulse is Full and Slippery, the condition is predominantly full. If the tongue has a thin coating (or no coating) and the pulse is weak in general, then emptiness predominates. In summary, the following are the features of full and empty conditions of Chronic Fatigue Syndrome.

Full conditions

Dampness in the muscles

Lesser Yang pattern

Yin Fire

Empty conditions

Qi deficiency

Yang deficiency

Blood deficiency

Yin deficiency

a) Dampness in the muscles

• pronounced ache in the muscles

• a feeling of heaviness of the limbs

• muscle fatigue on slight exertion

• tiredness and sleepiness

• feeling of heaviness of the body or head

• no appetite

• feeling of fullness of the chest or epigastrium

• a sticky taste

• poor memory

• lack of concentration

• a muzzy (fuzzy) feeling of the brain

• dull headache

• Tongue: a sticky tongue coating.

• Pulse: slippery

In case of Damp-Heat

• feeling of heat

• thirst but without desire to drink

• bitter taste

• slightly dark urine

• yellow vaginal discharge

• loose stools with offensive odour

• yellow tongue coating

Treatment principle

Resolve Dampness and if necessary, clear Heat

Herbal prescription

LIAN PO YIN

Coptis-Magnolia Decoction

ZHI SHI DAO ZHI WAN

Aurantium Eliminating Stagnation Pill

HUO PO ZIA LING TANG

Pogostemon-Magnolia-Pinellia-Poria Decoction

GAN LU ZIAO DU YIN

Acupuncture

SP 9 Yinlingchuan

SP 6 Sanyinjiao

BL 22 Sanjiaoshu

CV 12 Zhongwan

CV 9 Shuifen

LI 11 Quchi

SP 3 Taibai

ST 8 Touwei

TB 7 Huizong

GV 14 Dazhui

b) Lesser Yang pattern

There are two types of patterns pertaining to the Lesser Yang channels; one from the 6 Stages (from the Discussion of Cold-induced Diseases by Zhang Zhong Jing, c. AD 200), and the other from the 4 Levels (from the Discussion on Warm Diseases by Ye Tian Shi, 1742). They essentially describe the same pattern, the only difference being that the pattern from the 4 Levels involves more Heat.

Treatment principle

Clear the Lesser Yang

Herbal prescription

XIAO CHAI HU TANG

Small Bupleurum Decoction

HAO QIN QING DAN TANG

Artemisia-Apiacea-Scutellaria Clearing the Gall-Bladder Decoction

Acupuncture

TB 5 Waiguan

GV 14 Dazhui

c) Yin fire

• feeling of heat in the face

• red face

• mouth ulcers

• occasionally a low-grade fever

• dizziness

• weak voice

• depression

• muscle weakness

• exhaustion

• feeling cold in general

• loose stools

• cold feet

• spontaneous sweating

• shortness of breath

• Tongue: pale

• Pulse: weak

Treatment principle

Tonify the Original Qi (Yuan Qi), clear and subdue Yin Fire, raise Qi, resolve Dampness

Herbal prescription

BU ZHONG YI QI TANG

Tonifying the Centre and Benefiting Qi Decoction

Acupuncture

GV 14 Dazhui

TB 5 Waiguan

LI 11 Quchi

LU 10 Yuji

HT 8 Shaofu

SP 6 Sanyinjiao

d) Spleen and Kidney Yang deficiency

• tiredness which is worse in the mornings

• slight ache in the muscles

• muscle fatigue after slight exertion

• slight epigastric and abdominal distension

• loose stools

• lower backache

• weak knees

• frequent-pale urination

• dizziness

• tinnitus

• feeling cold

• cold feet

• Tongue: pale

• Pulse: weak and deep

Treatment principle

Tonify Spleen-and Kidney-Yang, resolve Dampness

Herbal prescription

YOU GUI WAN plus LIU JUN ZI TANG

Restoring the Right (Kidney) Pill plus Six Gentlemen Decoction

Acupuncture

BL 20 Pishu

SP 6 Sanyinjiao

BL 23 Shenshu

GV 4 Mingmen

CV 4 Guanyuan

KID 3 Taixi

KID 7 Fuliu

BL 52 Zhishi

GV 20 Baihui

Moxa should be used

f) Liver Blood deficiency

• tiredness

• muscle fatigue on slight exertion

• slight muscle ache

• blurred vision

• numbness of limbs

• dizziness

• scanty menstruation.

• Tongue: pale and thin

• Pulse: choppy or fine

Treatment principle

Nourish Liver-Blood, strengthen the sinews, resolve Dampness

Herbal prescription

BU GAN TANG

Tonify the Liver Decoction

Acupuncture

BL 18 Ganshu

BL 20 Pishu

BL 17 Geshu

LIV 8 Ququan

ST 36 Zusanli

Sp 6 Sanyinjiao

CV 4 Guanyuan

Moxa can be used

g) Yin deficinecy

The symptoms vary according to the organ involved. The three organs which most frequently suffer from Yin deficiency in CFS are the Lungs, Stomach and Kidneys. Combinations of two or even all three organs are common.

Lung-Yin deficiency

• dry throat

• dry cough

• exhaustion

• breathlessness

• hoarse voice

• feeling of heat in the afternoon

• night sweating

• Tongue: without coating (possibly only in the front part), there may be cracks in the Lung area

• Pulse: floating-empty

Treatment principle

Nourish Yin, generate fluids, and strengthen the Lungs

Herbal prescription

SHA SHEN MAI DONG TANG

Glehnia-Ophiopogon Decoction

Acupuncture

LU 9 Taiyuan

CV 17 Shanzhong

BL 43 Gaohuangshu

BL 13 Feishu

GV 12 Shenzhu

CV 12 Zhongwan

ST 36 Zusanli

SP 6 Sanyinjiao

GV 20 Baihui

No moxa

Stomach-Yin deficiency

• dry mouth

• no appetite

• tiredness

• dry stools

• slight epigastric pain

• malar flush

• thirst with no desire to drink or desire to drink only small sips

• Tongue: normal body-colour, midline crack in the centre, rootless coating or no coating in the centre, transversal cracks on the sides indicating chronic Spleen-Qi and Spleen-Yin deficiency

• Pulse: floating-empty on the right middle position

Treatment principle

Nourish Yin, strengthen Stomach and Spleen

Herbal prescription

YI WEI TANG

Benefiting the Stomach Decoction

Acupuncture

ST 36 Zusanli

SP 6 Sanyinjiao

CV 12 Zhongwan

ST 44 Neiting

GV 20 Baihui

Kidney-Yin deficiency

• soreness of the lower back

• exhaustion

• depression

• lack of drive and will-power

• weak legs and knees

• dizziness

• tinnitus

• deafness

• dry mouth and throat which are worse at night

• night sweating

• disturbed sleep (waking up during the night)

• thin body

• Tongue: without coating

• Pulse: floating-empty

Treatment principle

Nourish Yin, strengthen the Kidneys and firm Will-Power

Herbal prescription

ZUO GUI WAN

Restoring the Left (Kidney) Pill

Acupuncture

KID 3 Taixi

LU 7 Lieque & KID 6 Zhaohai together

CV 4 Guanyuan

SP 6 Sanyinjiao

BL 23 & BL 52 together

GV 20 Baihui

End notes

1. Shepherd C 1989 Living with M.E., Cedar, William Heinemann Ltd., London, pp. 14-16

2. Ibid., p.889

3. 1979 The Yellow Emperor’s Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen), People’s Health Publishing House, Beijing, first published c. 100 BC, p.21

4. Ibid., p.24

5. Ibid., p.24

 

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