Tired out: approaches to tiredness and fatigue

JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
TIRED OUT
by Hugh MacPherson and Richard Blackwell
Traditional Chinese medicine (TCM) will differentiate, Woman, 58, slightly overweight, cheerful, married, diagnose and treat according to the precise patterning of keeps fit by swimming twice a week. Her main the symptoms in each individual, and therefore has problem is tiredness which has been gradually get- much to offer in terms of a clear understanding of the ting worse over the past year. She feels tired much of causes and effective treatment of tiredness and fatigue.
the time, sometimes waking exhausted and often In this article we will focus on the problem of tiredness feeling "done in" by the end of the day. She has when it becomes pervasive and limiting in a person's recently been diagnosed as suffering from hypothy- life. First we will explore the Western medical perspec- roidism and has been prescribed Thyroxine.
tive and present those aspects which are most useful toacupuncturists in terms of diagnosis and treatment.
Woman in her mid thirties who has not managed to Second we will outline the aetiology and consequent get her energy back after childbirth 14 months ago.
pathology of tiredness and fatigue according to Chinese She suffered from post natal depression for about medicine. Examining aetiology is very useful, given that the first six months after the birth. The delivery itself patients who are very tired may well find lifestyle changes was long and painful and she was told that she had particularly beneficial in enhancing their Zhen ('True') lost a lot of blood. Now she feels she lacks the vitality Qi, without which change will be slow. Thirdly we will and interest in life that she used to have. She is present our identification of patterns which will be help- exhausted by the end of every day; this is not helped ful in drawing out the meaning of the signs and symp- by all the broken nights. She feels that she would be toms related to tiredness and fatigue. Finally we will O.K. if only she could get her energy back.
present two case histories where tiredness was the majorpresenting symptom.
Man, 62, who two weeks ago had a minor stroke. Hehad some temporary paralysis in his left arm and theleft side of his face which cleared within a few days.
WESTERN MEDICINE
He is now left feeling very tired and finds that he just The three cases described above illustrate some common cannot cope with the simplest tasks, for example categories of tiredness which may or may not be treat- able by Western medication or intervention. In the firstcase an underlying metabolic disorder (hypothyroidism) Each of these patients complained of chronic tiredness as was diagnosed, and Thyroxine was prescribed to rem- a major symptom, severely limiting their lives. As acu- edy the deficiency. It is probable that within a few weeks puncturists, we have been interested to note how many of taking the Thyroxine, the patient's energy will be of our patients have tiredness or fatigue as a primary or restored. However, for the TCM practitioner questions perhaps a major secondary complaint. This is a reflection remain about the underlying pattern which led to the of two things: firstly, many people with chronic and under-active thyroid, and constitutional treatment is debilitating tiredness have found little help for their desirable in addition to the Thyroxine. In the second case condition from Western medicine; secondly, acupunc- the patient is both physically and emotionally depleted turists have a reputation for working with Qi or energy, following childbirth and unless she becomes severely which is the level at which such people perceive that they depressed or blood tests show a low haemoglobin count, Western medicine would have little to offer. Similarly in Western medicine tends to prefer "objective" informa- the third case, extreme mental tiredness is the conse- tion about illness and so general practitioners often do quence of a stroke and there is no clear Western remedy.
not ask many questions about the quality and experience From the perspective of Western medicine, chronic of tiredness. There is also a tendency to approach the question of diagnosis in a reductive manner - either there •in some cases tests will indicate a serious underlying is some physical problem (e.g. anaemia, thyroid defi- pathology (e.g. anaemia, hypothyroidism, diabetes, can- ciency) or it is a 'psychological problem' and therefore medication such as antidepressants might be offered.
•tiredness can be a major component of a serious depres- More often than not no useful diagnosis can be made.
It is clear from the above case examples that the context •tiredness may also be a response to chronic pain (and and nature of tiredness is very different in each case.
untreatable as long as the pain is not controlled).
JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
•tiredness may be a side effect of certain Western drugs.
growth can lead to deficiency of post-natal Jing (as Anti-histamines, painkillers and antibiotics are well discussed above). Eating irregularly or erratically, and known for causing symptoms of tiredness in some indi- eating when stressed causes dysfunction of the Stomach viduals, but other drugs such as beta-blockers can also and Spleen. This may then lead to Qi and/or Blood Xu.
have this effect. Medication should always be consid- Spleen-Qi-Xu can also lead to the formation of damp- •tiredness often develops at a time of hormonal change (e.g. puberty, pregnancy, after childbirth, menopause).
Retained pathogenic factor: subsequent to the invasion •tiredness may often follow a serious illness or may of external pathogenic factors in the form of cold, heat, occur post-virally, as in M.E. (Myalgic Encephalitis - wind or damp, alone or in combination, a portion of the Post-Viral Syndrome, Chronic Epstein-Barr Virus Dis- invading factor may remain in the body. This will occur •tiredness is often labelled 'psycho-social', and can be - already very weak, and their Zheng-Qi (anti-patho- one of the responses of a person coping with a life that genic Qi) is insufficiently strong to expel the Xie-Qi they do not really want to be leading. This can be a (pathogenic Qi). The person may be constitutionally "bucket" category for patients who do not fit any other weak, or may be temporarily exhausted, for example by category, and tends to carry the usual pejorative over- tones. Because it lacks detail and explanatory power, this diagnosis seems rather inadequate from a TCM perspec- tive, which would seek to be much more specific about When this occurs the remaining pathogenic factors may When to refer patients for a Western medicine diagnosis: one transform into interior heat, damp-heat, damp or phlegm should be alert to any symptoms suggestive of one of the and become chronic. In terms of the Four Stages the serious underlying pathologies listed above. In addi- retained pathogenic factor is usually seen at the Qi level tion, and as a general rule, any patient who complains of and treatment is via the zangfu. Long term retention of tiredness which is progressively getting worse for no pathogenic factors, i.e. for more than a few months, will apparent reason should be referred for investigation by lead to depletion of Qi and Yin. The diagnosis and Western medicine, concurrent with acupuncture treat- treatment of patterns with this aetiology have been discussed in more detail elsewhere.*• Chronic stagnation of blood: chronic blood stagnation can TRADITIONAL CHINESE
lead to blood deficiency. When old blood remains and is MEDICINE
not expelled, the Spleen cannot make new blood. Like-wise chronic stagnation of Qi may lead to Qi deficiency.
Aetiology and its Pathological
• Chronic disease: if chronic disease persists for months or consequences
years it will eventually deplete the Kidney, includingKidney-Jing.
It is particularly important to know of any aetiologicalfactors that have led to a patient being tired and fatigued.
• Emotional factors: repressed emotions easily lead to A clear understanding of the aetiology is essential in stagnation, commonly the pattern of Liver-Qi Stagna- helping the practitioner to know the ways in which tion. The Qi stagnation may then generate heat, or alter- patients can help themselves. These patients are often natively excessive emotion can generate heat directly.
keen to help themselves and are likely to respond well to The heat in turn may interact with Spleen-Qi-Xu and support in making appropriate lifestyle changes. When retained dampness to generate damp-heat. Also, in some tiredness is the key symptom, changes in lifestyle can cases Liver-Qi Stagnation may give rise to dampness by often make a significant difference to the outcome.
causing stagnation of the Spleen's transforming and The following factors are of major significance when considering the aetiology of chronic fatigue: Sadness can deplete Heart and Lung-Qi; anxiety, worry • Conception by older parents or parents in poor health, or poor and over-thinking can deplete Heart-Blood and Spleen- emotional and physical nourishment in childhood or puberty: Qi; or deep-seated anxieties can deplete Heart and Kid-ney Yin. Emotional factors are often an important part of these factors result in pre-natal or post-natal Kidney- the aetiology in patients complaining of tiredness. The Jing deficiency, which in turn can lead to Kidney-Yang- interaction between emotional factors and symptoms Xu, Kidney-Yin-Xu or Liver/Heart Blood-Xu.
can be quite involved, reflecting the emotional com- • Excessive sex, many pregnancies: these factors can de- plexities of modern life, and really merits an article of its plete Kidney-Jing, leading to the development of further syndromes such as those discussed above.
Acupuncture will frequently begin a process of change • Childbirth: if the mother overworks or gets insufficient and growth in the individual which can profoundly rest after giving birth she will easily become Qi-Xu, affect these emotional factors. However, in some cases better results are achieved when patients receive coun- • Overwork: working continuously without a break for selling from a trained psychotherapist in addition to long periods of time consumes Qi and Yin.
• Irregular diet: lack of nourishment at a time of rapid *("Myalgic Encephalitis" by Giovanni Maciocia, see Appendix).
JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
• Wear and tear (Lao): the Chinese word 'Lao' denotes ence their tiredness are listed in detail to assist pattern continual wear and tear of various aspects of the body over extended periods of time. Lao is translated in vari- Spleen-Qi-Xu
ous ways, e.g. as fatigue, taxation or consumption (be-cause essential substances or tissues are consumed).
- tiredness which may be low level and chronic According to the Nei Jing: 'Looking for too long damages the blood; lying for too long damages Qi; sitting for too long damages the flesh; standing for too long damages the bones; walking for too long damages the sinews.' - if accompanied by Lung-Qi-Xu: breathless with activ- Taking these one at a time : i. Straining the eyes for long periods depletes Liver-Blood. This may be one effect of - if accompanied by Heart-Qi-Xu: palpitations with over-use of the VDU screen, and it may help to explain the prevalence of short sightedness in literate cultures. ii.
Lying down for too long leads to inadequate exercise which damages Qi. The Qi becomes sluggish and stag- People with patterns of Spleen-Qi-Xu find that their nant and this gradually leads to deficiency. Also, lying tiredness is worse after eating, especially after large down weakens the breathing process and so weakens meals, or after eating rich food or food which is heavy the Lung-Qi. iii. Maintaining any one posture for long and difficult to digest. They tend to feel better for a hot periods causes Qi to stagnate in some areas and become drink. They are quickly tired from concentration and depleted in others, causing damage to the flesh and mental work, and are better for lying down, and better muscles. Also, as in (ii.), the lack of exercise damages Spleen-Qi, which in turn weakens the flesh. iv. Standing Kidney-Yang-Xu
for long periods over many years damages the bones.
This particularly applies to the weight-bearing areas of the spine, hips, legs and feet. Because the Kidneys gov- ern the bones, Kidney-Qi also becomes depleted. v. Walk- ing excessively long distances easily causes damage to the tendons and ligaments. Similar effects arise from - worse after defecation, defecation may be difficult excessive running (e.g. marathons), swimming and ath- letics. The Hui (influential) points may be appropriate as part of the treatment of wear and tear. For the five Lao the following five Hui points can be used respectively: Geshu BL-17, Shanzhong REN-17, Zhongwan REN-12, Dazhu This pattern is often characterised by extreme and disa- bling fatigue. Some people with patterns of Kidney- Identification of Patterns
Yang-Xu will speak of having low motivation, otherswill describe how they have to plan their activities 'Tiredness' is very much an umbrella term, and in fact carefully because their energy resources are so limited.
this symptom manifests in many different ways. The They will often feel temporarily better after a hot bath.
specific variations in patients' experience of their tired-ness can be incorporated into the process of diagnosis by Dampness distressing the Spleen
asking questions such as: what time of day the tiredness and channels
is worse, whether it is felt in the head (muzziness etc.) or body (weak limbs etc.) or both, whether it is made worse by activity, eating, defecating etc., whether there is an emotional component, with feelings of depression, anxi- ety etc., whether specific situations increase the feeling - poor concentration, 'woolly', 'muzzy', 'fuzzy' of tiredness (going to work, problematic relationships - lethargy and heaviness of the body, head or limbs Patients expectations as to what constitutes their nor- - pressure in the head, feels heavy and aching mal level of energy are quite variable and it is as well to clarify these expectations before commencing treatment.
It can be useful to discuss the importance of a good - dragging, drooping sensation e.g. of the jaw balance between rest and activity, especially with pa- tients who expect to be capable of non-stop activity day - may be muscle fatigue after exertion (if with Spleen/ after day. It is also helpful to establish a number of ways to monitor changes, for example by noting patients' ability to accomplish physical tasks, or their time-span of effective concentration, in addition to their general per-ception of energy and well-being.
People with patterns involving dampness find that eve- Chronic tiredness, weariness, exhaustion and fatigue rything is an effort, and they complain of feelings of can be associated with a wide variety of patterns, both heaviness and sluggishness. They find that they fre- Xu and Shi. The most common patterns are listed below, quently want to lie down, and they sleep a lot. They may and for each pattern, the ways in which people experi- feel worse after sleeping, but in some cases may be better JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
for a short rest. Also characteristic are feelings of being nap, and after relaxation, and people with these patterns weighed down psychologically, and feelings of depres- generally feel better for relaxing and sleeping more, working less hard, and nourishing themselves well both The tiredness is worse for heavy, high fat food, dairy foods, cold foods, and raw foods, whilst it is better for Kidney/Heart Yin Xu
light foods (e.g. rice, vegetables, and fish), better forwarm and cooked food, and better for fasting.
It is notable that the tiredness seen in these patterns is - no energy, but unable to relax properly more stubborn, heavy and difficult to get over than that - better with relaxation, massage- concentration deteriorates later in the day Damp Heat distressing the Spleen
and channels
- as for Damp with some signs of Heat, especially thirst Tongue: red, cracked, red tip, rootless coating or no If Kidney-Yin-Xu with Liver-Yin-Xu and Yang rising:
Phlegm patterns
General symptoms:
This pattern brings with it the unpleasant combination of feeling exhausted yet simultaneously over-stimu- lated. There are a multitude of terms to describe this feeling, for example people may speak of feeling 'edgy', 'jittery', 'burned out', 'jagged', or 'jet lagged'. Patients talk about wanting to do more, and they experience anxiety about all the things they feel they should bedoing. One consequence of this is that patients feel better Phlegm in the Channels:
for a while following treatment, and then they do too much (because they want to 'take on the world') and get Phlegm misting the Heart:
worse. Also, the restless energy which is felt is often used - blanking out, periods of 'not being there' in a scattered, unfocused way. This pattern is worse for - being unable to do even simple tasks, because of overwork, coffee, tea, and other stimulants.
People with these patterns have often been ambitious and driven, and the feeling of tiredness can lead to them Phlegm in the Lung:
being unable to cope with their work. Loss of pride and Liver Qi Stagnation
People with Phlegm patterns often describe feeling dis- tanced and cut-off, and feeling not fully there.
These Phlegm patterns of tiredness can also be associ- ated with other pathology involving Phlegm, such as - energy rises after exercise or other activity Meniere's disease or the sequelae of stroke.
- difficult to get started in the morning Liver/Heart Blood Xu
- better for relaxation, especially of the muscles - limbs and extremities tight and numb - worse when The tiredness experienced in this pattern is typically a - more anxious when tired, sleep is worse when tired feeling of "I can't be bothered", and is sometimes de- * all these symptoms are worse after menstruation scribed as "that Monday morning feeling". People with this pattern feel tired and stuck and often cannot see the broader view. As a result they may lack flexibility and People with Blood-Xu patterns experience a lack of can tend to stick to one way of doing things.
vitality, and they lack resilience against the everyday It is characteristic of people with Liver-Qi Stagnation stresses of life. They find that everything is an effort who feel tired that they will often describe feeling irri- because of the anxiety which is generated, and they feel tated and annoyed by their tiredness. They are able to drained and weak (some will even say that "the life find energy for activities which are personally important blood is not there"). The tiredness is better after a cat- and which enthuse them, and once their energy is mov- JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
ing (with activity) they discover that more energy is available. The tiredness in this pattern is better for laugh- - gets annoyed with herself for getting tired Case Study 1
- little interest in eating (Liver invading Stomach)- pre-menstrual tension with irritability and swollen Anne is a single woman aged 31. She is a driving instruc- tor, often working long and irregular hours. She has lived with her parents for the past three years since the break up of her relationship with her partner. She is very thin and rather pale and listless. Her main problem is Spleen-Qi-Xu (leading to Spleen-Damp):
tiredness. She says she can no longer find any energy and - tiredness where everything is an effort that this makes her existence pointless. She describes having felt extremely tired, mentally and physically, for the past two months. She says that she feels 'limp' and no longer has any incentive to do anything. She finds it very - tongue slightly swollen and slightly wet difficult to make decisions and hard to face going to - pulse thready on right (indicates Blood-Xu due to a work. Sometimes she nearly falls asleep when giving lessons, and her body and legs feel heavy. Everythingfeels like an effort and she gets annoyed with herself for Aetiology: the trauma of the break-up of Anne's relation- being so tired. Although she seems friendly and is articu- ship three years ago and the subsequent emotional stress late, Anne says that she has few friends, because she is have led to Liver-Qi Stagnation. This is exacerbated by too tired to socialise. Anne also feels very depressed and her ongoing sadness and anger about this relationship irritable and says that this has developed over the past and her social isolation. Her work as a driving instructor three years since her relationship ended. Although she is stressful and also quite insecure in a time of recession.
describes her ex-partner as being a jealous, possessive Irregularity of eating because of her work and her lack of and violent man, she found carrying out her decision to appetite, associated with a tendency to eat when she is leave him extremely painful. She remembers having stressed and to eat cold food (such as yoghurt, salad) bouts of severe diarrhoea and vomiting at this time, straight from the fridge, have weakened her Spleen.
which she associated with the trauma of their separation.
Pathology: Liver-Qi Stagnation and Spleen-Qi-Xu are She still frequently feels slighted nauseated. She has just conditions which interact and give rise to dampness.
started having counselling sessions to help her to come Weakness of the Spleen's transforming and transporting to terms with the lingering unhappiness and anger from functions allows dampness to form. The Spleen defi- the split. She has a tendency to be constipated and to ciency also makes it easier for the Liver to invade, and bloating in her mid-abdomen after eating. She cannot this then prevents the Spleen-Qi from flowing smoothly, pinpoint any particularly aggravating foods, and is a which allows the dampness to accumulate further.
vegetarian eating little dairy food. Most of the time she The weakened Spleen is unable to effectively absorb doesn't feel like eating and eats very little. She lost two nourishment, and this has lead to early signs of defi- stones after the end of her relationship and her weight ciency of Blood and Yin, with the thready pulse, loss of has been at seven stones for the last two years. She stopped taking the contraceptive pill two years ago and Treatment Principles: Ease the Liver, tonify Spleen-Qi.
has had no periods since then. She does not seem to be Treatment plan and lifestyle advice: twenty treatments twice worried about this. Before she started taking the pill she weekly were advised. Anne was encouraged to continue remembers having irregular periods with some pain at her counselling sessions to talk through her emotional the start of the period. She also used to have pre-men- problems. It was explained that acupuncture would help strual tension, with irritability, bloating and swollen her emotions to flow more smoothly and that counsel- breasts. She has fairly frequent sharp pains above her ling concurrent with acupuncture treatment could well eyes and at the back of her head, often when she is sitting help her to move forward. She was also advised to think quietly after a day's work. Anne's general health has about her diet; to eat regularly and to try to eat in a been good, apart from an episode of 'glandular fever' in relaxed frame of mind. It was suggested that she tried to her teens, which dragged on for a long time and pre- avoid cold, raw food as well as dairy products, and that vented her from taking her O-level examinations. She she based her meals on warm cooked foods, or at least does not smoke, drinks little alcohol and for the last few had a warm drink at the same time, to assist the digestive months has been taking regular exercise at a gym. Her tongue is purple, slightly swollen and slightly wet withmany cracks. Her pulse is wiry on the left and thready on • Neiguan P-6 to smooth the flow of Liver Qi, to harmo-nise the Stomach and so to improve appetite.
Identification of patterns: The main patterns that can be • Zusanli ST-36 to tonify the Stomach and Spleen and identified are listed below in order of significance, with • Taichong LIV-3 to ease the Liver.
Liver-Qi Stagnation:
• Hegu L.I.-4 ('Four Gates' with Taichong LIV-3) to calm - tiredness and lack of incentive and motivation the Shen and facilitate the movement of Liver-Qi.
- difficulty in making decisions (involvement of Gall • Other points used at times: Zhongwan REN-12, Qimen JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
thready and slippery. Her tongue is a normal colour, Progress and outcome: Anne has had twelve treatments swollen with a greasy yellow coat and red tip.
and her treatment is ongoing. She felt shaky but relaxed Identification of patterns: the two main syndromes which after her first treatment, and continues to find treatment can be diagnosed in Kate's case are Spleen-Qi-Xu lead- relaxing. There have already been some marked changes ing to dampness, and Liver-Qi Stagnation/Liver Yang in the way that she looks and feels. There was an almost Rising. The symptoms associated with these patterns are immediate increase in her energy, which has improved with each treatment and this is visible in her presenta- Spleen Qi Xu leading to dampness:
tion. There is more 'spirit' in her eyes, she smiles and laughs more and talks about her plans for the future; she says she has a "sense of movement" and that she is "learning to like herself again". She now feels that she has the mental and physical energy to act on the ideas that emerge during her counselling sessions. In general her abdominal symptoms are improving with less constipa- Liver Qi Stagnation/Liver Yang Rising:
tion and bloating. Her limbs and body feel less heavy and she no longer feels like falling asleep during the day.
These changes indicate that treatment has already begun to activate the stagnant Qi and ease the Liver, - frustration and tension associated with loss of sight and causing a notable reduction in her 'stuckness'. However there was a definite setback between the seventh andeighth treatments when more symptoms of dampness Aetiology: Kate has a long-term and very serious commit- and Qi-Xu appeared, including tiredness, heaviness and ment to her academic work, and is depressed and frus- constipation, nausea and poor appetite. This may indi- trated by the obstacles which her poor sight and ill health cate some movement of the dampness as the stagnant Qi put in the way of her progress. Her single-mindedness moves. These are now largely under control again, and coupled with frustration will stagnate her Liver-Qi. Long the prospects for further improvement look good.
hours of intense mental work with concomitant irregu-lar eating habits are likely to have weakened her Spleen.
The Spleen's inadequate transforming and transporting Kate is a 34 year old PhD student in Sociology who lives function will have allowed Dampness to develop. This with her partner. She has been diabetic since she was may have been further exacerbated by her medication, nine, and says that her diabetes is now well controlled particularly the anti-inflammatories, which although with insulin. She is completely blind in one eye and reducing heat in the joints appear to generate increased partially sighted in the other as a result of progressive diabetic retinopathy over the last five years. She has a Anti-depressants have side effects which include dry guide dog and is fairly mobile. In spite of her health mouth, constipation, tremor, headaches and rashes and problems Kate comes over as a positive, humorous and they aggravate the mania of manic-depressive patients.
They appear therefore to be hot and to raise the Yang, She is complaining of extreme tiredness which is inter- which would aggravate the symptoms of Liver-Yang fering with her studies. She finds that she has to sleep for most of every afternoon, and her concentration is very The pattern of Liver-Qi stagnation may contribute to poor. Her energy is low and her limbs feel heavy. She the controlled single-mindedness required to research sleeps heavily at night and does not feel refreshed when and write a PhD thesis, but at the same time this type of she wakes in the morning. The tiredness started about work will easily cause further stagnation. The same is two years ago, and is now seriously interfering with her true of depression, which is perhaps the other side of the work and her social life. In addition, Kate has an coin of the hard work and drive needed to do successful underactive thyroid gland, diagnosed when she was research. Kate's on-going frustration about her poor fifteen, for which she takes Thyroxine. She has a painful health will exacerbate this pattern and cause the stagna- and swollen hand, diagnosed as 'arthritis' for which she tion to transform to heat and ascend as Liver-Yang takes Voltarol, (a non-steroidal anti-inflammatory drug).
Rising. In addition, her habits of excessive coffee drink- She describes the hand as "burning" and feeling "bruised".
ing and cigarette smoking will scatter Qi (giving some She is also depressed, with the depression becoming temporary relief from stagnation), but eventually de- more severe since her eyesight deteriorated two years plete Yin, leading to empty heat and further rising of ago. She has been prescribed Fluanxol for this (an anti- psychotic drug which is also used in the treatment of Pathology: the presence of Liver-Yang Rising indicates depression). She describes herself as being tense and that there is probably an underlying deficiency of Yin in frustrated because of her tiredness and poor sight, and Kate's case, as well as the Liver-Qi Stagnation. This is often feels stiffness and tension in her shoulders associ- borne out by the fact that she was diagnosed as diabetic ated with this. She drinks ten to fifteen cups of strong twenty-five years ago. In TCM diabetes is known as expresso coffee a day and eats a balanced diet with little 'thirsting and wasting disease' and the symptomatology meat. She smokes up to twenty cigarettes a day and (before it is controlled) indicates the presence of empty would like to give up smoking. Her pulse is deep, heat, usually associated with Kidney-Yin deficiency.
JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
The red tip to the tongue is a sign that this underlying Liver-Yang. About six weeks after starting treatment deficiency is still present. In addition Liver-Qi Stagna- Kate's research work was flowing more smoothly and tion over a long period can cause Liver-Yang to heat up and rise, giving symptoms such as irritability, tension of By the tenth treatment Kate said that she was ready to the neck and shoulders, and eye problems.
stop smoking, and Lieque LU-7, Neiguan P-6 and ear The progressive loss of vision which has occurred at points Shenmen and Upper Lung were added to the such an early age is also a strong pointer to a severe prescription. She stopped smoking without great diffi- underlying Kidney-Yin deficiency, which undermines culty. There was another brief episode of instability with the strength of Liver-Blood. The diagnosis of underactive the insulin but this was resolved. The neck and shoulder thyroid also indicates that there has been a problem of pain settled and her energy was much increased. She Kidney-Yang-Xu, although again the medication will was getting on well with her academic work and was mask the symptoms of this pattern. It is possible that this pleased with the quality of her research.
deficiency of Kidney-Yang was a contributory factor to Four months after stopping treatment, Kate still has a the pattern of Spleen-Qi-Xu and dampness.
good level of energy and concentration. She has not Treatment principles: tonify Spleen-Qi, resolve damp, ease started smoking again. She has periodic problems with Liver-Qi and sink rising Liver-Yang.
pain in her wrist which sometimes prevents her typing,and is considering having acupuncture treatment for Treatment plan and lifestyle advice: Kate was advised to this. She dislikes taking the anti-inflammatory medica- have ten treatments twice a week. It was suggested that tion and painkillers, and says that she would also like to she should avoid dairy foods and eat warm nourishing stop the anti-depressants. She says that she went for food, particularly pulses and vegetables. It was agreed acupuncture treatment with no expectations and found that later on, when she was feeling less stressed, tired that it took her quickly out of a difficult phase.
and frustrated, the issues of stopping smoking and drink-ing less strong coffee would be addressed. While it was Short Cases
acknowledged that she would need to take insulin and Symptoms of tiredness and fatigue can be associated Thyroxine permanently to control her diabetes and sup- with a wide variety of patterns, as illustrated by the three port her underactive thyroid, it was agreed that as treat- cases described at the beginning of this article: ment progressed she could aim to discontinue taking the • First case (woman 58): her diagnosis was Spleen-Qi Xu anti-inflammatory medication and the anti-depressants.
with some dampness. She decided to go ahead with the By explaining TCM pathology to Kate she was able to Thyroxine in parallel with a course of ten acupuncture understand how both these drugs might in fact be in- treatments. She very quickly recovered her energy, and by the third treatment she no longer experienced tired- • Zusanli ST-36, Taibai SP-3, Sanyinjiao SP-6, YinlingquanSP-9, Pishu BL-20 and Zhongwan REN-12 all to tonify • Second case (woman - mid-thirties): a clear case of Spleen Qi and resolve dampness. Taibai SP-3 is particu- Liver-Blood Xu caused by the blood loss at childbirth.
larly indicated for lack of concentration.
Acupuncture was used to tonify blood. Lifestyle and • Hegu L.I.-4 and Taichong LIV-3 to calm the Shen and dietary changes were important in this case to speed recovery. Key factors were: eating warm and cookedfood and warm drinks as a basic requirement, and Progress and outcome: Kate attended the clinic for acu- organising sufficient rest. She slowly regained her en- puncture treatment sixteen times over a period of two ergy and zest for life with treatment over a period of and a half months. Her response to treatment was swift and dramatic, with a great reduction in tiredness and • Third case (man - 62): the precipitating factor in his lack of concentration straight away. By the fourth treat- stroke were Liver-Wind, internal heat and phlegm. Treat- ment she was able to work through the afternoon, and ment in the first instance was directed towards sedating the symptoms caused by the dampness were diminish- the Liver and the heat to ensure his condition stabilised.
ing. The upsurge in her energy brought about by treat- The residual component of the stroke which continued ment led to an imbalance in her blood sugar. She had to affect him was the phlegm. Treatment therefore moved several hypoglycaemic attacks but these were controlled more towards clearing the phlegm so that he could by an adjustment in the insulin intake.
regain his mental abilities. He came for treatment twice In the period between the fifth and the eighth treat- weekly for several months with gradual yet noticeable ments she was having some episodes of moodiness, improvement. After six months he was fully recovered.
tearfulness and anger, and the shoulder tension tempo-rarily increased. She felt frustrated because she was not CONCLUSION
getting on well with her work, and was also dissatisfiedwith what she did produce. For a short time she thought TCM is able to recognise a range of patterns of dishar- about giving it up. This seemed to indicate a freeing up mony associated with tiredness, and the nature of the of emotion and feeling which had been held in by the tiredness is itself characteristic of the underlying pat- stagnant Qi. The prescription was altered, eliminating tern. A grasp of these patterns enables us to treat tired- the Spleen points which had been used to resolve the ness in the specific context in which it occurs in each dampness and including Jianjing GB-21 and the Huatuo individual. A TCM diagnosis includes an understand- point at C7, with Houxi SI-3 as a distal point for the neck ing of aetiology, which can be extremely helpful in and shoulder pain, and Fengchi GB-20 for the rising assisting patients to identify causes and hence to take JOURNAL OF CHINESE MEDICINE NUMBER 40 SEPTEMBER 1992
effective remedial action. Finally treatment by acupunc-ture frequently produces striking improvements in thesecases, liberating people from the limitations imposed bytheir patterns of disharmony. This is a field where Chi-nese medicine has a valuable contribution to make.
APPENDIX 1
Three abstracts of articles on the treatment of tirednessare presented here. The subject has received scant atten-tion in the literature, and we have been unable to traceany papers on the subject from China, partly becausepatients complaining of tiredness will often be catego-rised as suffering from neurasthenia in contemporaryChina.
• Buchwald D, Blair J, Mease P. Treatment of ChronicFatigue Syndrome with Acupuncture. Int. J. Clin. Ac. 1991;2 (3): 231-236. Eighteen adults who had suffered withchronic fatigue for at least 6 months, most commonlyfollowing viral illness, received a course of 15 acupunc-ture treatments combined with Chinese herbal medi-cine. Treatment plans were individualized, but the fa-tigue component was seen as always due to Kidney-Yang-Xu (Shao Yin syndrome). Treatment included QihaiREN-6, Zusanli ST-36 and Zhaohai KID-6, plus otherpoints according to the individual case. Patient-reportsymptom questionnaires showed that fatigue, myalgia,post-exertional fatigue, arthralgias and neurocognitionimproved in 61% of patients. Fatigue, myalgia and ar-thralgia showed the most improvement. Ability to per-form daily activities increased in 83% of patients. Finalconclusions are tentative due to the short duration oftreatment and the erratic natural course of the disease.
• Cohen M. Chinese Medicine in the Treatment of ChronicImmunodeficiency: Diagnosis and Treatment. Am. J. Ac.
1990; 18 (2): 111-122. This article focuses on HIV infec-tion, AIDS and ARC, but also considers Chronic Im-mune Dysfunction Syndrome (aka Chronic Fatigue Syn-drome). The aetiology, diagnosis and treatment by acu-puncture and Chinese herbal medicine are discussedand there is a detailed discussion of the wider issuesinvolved in evolving a treatment strategy.
• Maciocia G. Myalgic Encephalitis (Post-Viral Syndrome,Chronic Epstein-Barr Virus Disease). J. Chin. Med. 1991; 35:5-19. A detailed discussion of the aetiology, diagnosisand treatment of these conditions by both acupunctureand Chinese herbal medicine. Syndromes discussed areDamp-Heat in the Muscles, Heat Lurking in the Interior,Lesser Yang Pattern, Qi Xu, Yin Xu and Yang Xu. Illus-trative case histories are presented throughout.
Acknowledgements:
Many thanks to Cathy Ballard for her help in producingthis article, to Dr. Han Liping for translating material onaetiology, and to the post-graduate training group at theNorthern College for their ideas and suggestions.
Hugh MacPherson and Richard Blackwell are Principal andFaculty Member respectively of the Northern College of Acu-puncture, England. Both have practised acupuncture for manyyears.

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