Discourse on the TCM Pathogenesis and Treatment of Chronic Fatigue Syndrome
by Wang Yi Li and Yan Yu Ming
Zhe Jiang TCM Journal  December 2001, Vol 36, No 12

The pathomechanism, etiology and treatment
for Chronic Fatigue Syndrome with TCM

    Chronic Fatigue Syndrome (CFS) has garnered attention for close to 20 years.  Knowledge of the disease continues to grow and deepen.  However, due to the limitations of biomedicine and the vicissitudes of this particular disease, modern medicine has not been unable to fully elucidate the understanding of this condition. 
    In looking at historic research in Chinese Medicine regarding bai he bing, hysteria, vacuity damage, consumptive disorder as well as a wide variety of syndromes of stagnation and depression there is overlap with some of the symptoms seen in CFS.  However, there is no single TCM pattern which completely encompasses CFS.   Therefore the only hope of obtaining optimal treatment outcome lies in freshly examining the symptoms and pathomechanism for each individual situation.   For this reason I have combined contemporary research with historical literature to develop my own understanding regarding disease etiology and pathological characteristics from a TCM perspective which I will now explain. 

Disease Etiology

     In modern biomedical research there is no definitive lab test which positively diagnoses CFS.  Western medicine, especially abroad, generally employs the Center for Disease Control (CDC) 1987 diagnostic criteria.  There are 2 primary criteria of diagnosis.  The first is fatigue characterized by recent occurrence which persists, or occurs repeatedly, is not relieve by rest and last more than 6 months.  The second is effectively a diagnosis of exclusion (i.e. fatigue the reasons for which cannot be explained adequately by medical history, lab tests, medical signs etc.).  In order to positively diagnose a patient with CFS, eight or more of the signs and symptoms below must be present:  1) low grade fever, body temperature not exceeding  38.5ºC [101.3 ºF], 2) nonexudative pharyngitis, 3) inflammation and tenderness of the submandibular or axillary lymphnodes, 4) muscle discomfort or myalgias, 5) unexplainable muscle weakness, 6) prolonged fatigue (>24 hours) after exercise or exertion, 7) migratory arthralgia without joint swelling or redness,  8) generalized headaches (different compared to those the patient has experienced in the past), 9) neuropsychologic effects (including forgetfulness, excessive excitability, clouded consciousness, poor concentration, depression etc.), 10)  sleep disorders (insomnia or drowsiness). 
    When looking at the primary and secondary diagnostic criteria a clear connection between all of these signs and symptoms is lacking.  However, they all certainly influence the functioning of the nervous system, endocrine system, immune system and digestion.  In CFS patients lab values do not generally show significant abnormality, although in assessment of the immune function some patients do have higher load of anti-viral antibodies.  It’s not really clear what the relationship is between these abnormal lab results and CFS.   It is because of this insufficient understanding that current treatment is inadequate. 

1.2       Chronic consumptive disorder, vacuity of what is upright and depressed evil form the basic etiology CFS.   In order to inform one’s understanding of CFS, one can look to historic records of TCM regarding laziness xie duo, sluggishness xie dai, 4 limb sluggishness si zhi lao juan,  4 limb heaviness si zhi chen zhong,  4 limbs weak and limp  si zhi tan ruan etc.   When the spirit and physical strength are overextended for a long period, the Sheng Ji Zong Lu chapter on consumptive disorder states “overexertion when severe will result in extreme body fatigue.”  If done repeatedly, this will certainly consume and harm the body, qi, blood and body fluids and influence physiologic function the Zang Fu.  The Nei Jing’s Xuan Ming Wu Qi Pian, Zhang Zhong-Jing’s discussion of Shaoyang disease, Bai He Bing, Hysteria, as well as more contemporary authors like Li Dong Yuan [Pi Wei Lun] Treatise on the Spleen & Stomach; all of these historic sources have examined these patterns and have valuable knowledge to contribute to the understanding of CFS.
    The Nei Jing states “When the Zheng qi is preserved internally, evil cannot interfere,” excessive work or unrestrained emotion results in inevitable injury of the Zheng qi.  When the Zheng qi is vacuous, correct function of the Zang Fu is difficult to sustain;  the Ying and Wei will not be harmonized, the qi dynamic will be depressed, qi transformation will be inhibited, Spleen transportation will be stagnant.  An entire series of pathological phenomena can arise.  Furthermore, when Zheng qi is deficient & vacuous, external evils can take advantage of the situation and attack.  This can cause internal pathological accumulation of evil thereby engendering quantitative and qualitative change.
    Nowadays at home and abroad many researchers look to a variety of chronic infections as having an influence on CFS including frequent upper respiratory infection, the Epstein Barr virus, HIV, Herpes virus etc.  This way of looking at things has its reasoning, however this research is only in nascent stages and must expand.  Given the way TCM looks at things (through symptoms, analysis, categorization), two ideas have been put forward as significant both theoretically and clinically:  “vacuity of what is upright”, and “evil toxin”.


2 The basic pathomechanism for CFS drawn out of unique characteristics which arise from pathological loss of regulation of multiple Zangfu organ systems 

2.1     Qi & Yin are vacuous. Spleen and Stomach are internally injured.  Qi vacuity is a clear component of the normal onset of CFS. Qi vacuity fundamentally relates to the Spleen and the Lungs.  A person’s qi, blood and body fluids are supported and engendered by the Spleen.  The essence is distributed by the Lung in order to irrigate the Zang Fu, moisten and nourish all vessels. However, in CFS patients longtime work related stress and dietary irregularity cause the middle qi to be insufficient and the source qi to be internally injured.  Evidently these factors will further impact the Yin and blood.   The Yin is deficient therefore the Yang flourishes engendering heat and dryness.Clinical signs include low grade fever, pain in the larynx, dry throat, heart vexation and other signs.  Qi deficiency concurrent with insufficient Yin and fluids easily changes the body’s  internal environment. This type of change is multifaceted resulting in abnormal function of the endocrine glands, hormone secretion, immune cells function, release and activation of all elements which participate in metabolism and nutrition, supply energy, regulate and control the body.  The fact that CFS impacts so many systems necessitates approaching treatment from a multifaceted perspective. 

2.2 The Qi mechanism loses regulation.  Evil toxin accumulates inside.  With regard to the fundamental pathology of CFS, ”evil repletion” is one aspect which cannot be disregarded.  Qi and Yin vacuity are present. While they are commonly the principle underlying causes of pathology, still the imbalance of the qi mechanism and evil toxin attacking the interior are also critical components.  In looking at western biomedicine, what TCM calls the Six [Disease] Factors and Pestilential Qi are in fact many kinds of pathogenic microorganisms.   When the immune system is deficient, these [disease factors/microorganisms] will attack and can induce CFS. 
    From a different view, Qi and Yin being insufficient relate to evil toxin being a causal factor.  The Qi and Yin of a person are vacuous.  Consequently a patient’s emotions will be depressed; the Zang Fu Qi dynamic will be stagnant; the Qi and blood will not move smoothly; metabolism will be obstructed all resulting in the pathological consequence of internally generated turbid phlegm and [pathologically] stored blood.  These pathological byproducts cannot be naturally expelled.  They remain for a prolonged period of time and this process can lead to evil poison.
     From yet another perspective, these pathological substances accumulating in the body can weaken the Zheng qi and further exacerbate the loss of normal regulation within the Zang Fu dynamic. In clinical practice one sees many combinations of vacuity and repletion.  Pure vacuity or pure evil repletion are rarely seen.  Which is predominant differs from one person to another, with vacuity patterns tending to be more common.  


TCM Treatment

3.1     TCM treatment is superior.  For CFS the prognosis is generally quite good.  However, the disease can seriously affect a patient’s quality of life and [consequently] appropriate treatment is essential.  The research of this disease by contemporary medical science is in only the early stages.  There is no effective cure.  One should treat symptomatically.  Western biomedical treatment is relatively inflexible and not very effective. 
    At present, some of the elements which give TCM advantage over western biomedicine  in the treatment methods and medications [for CFS] are as follows.  1) Lengthy history of medical records which hold abundant research and empirical evidence. 2) An individual practitioner can adopt his own system of understanding disease patterns, analysis and conclusion regarding the etiology, cause and pathomechanism.  One can thoroughly establish a principle of treatment in accordance.  3) According to every stage of CFS, one can carry out treatment based on different clinical pattern differentiation; correcting the upright and dispelling evil, boosting Qi and nourishing Yin, transforming phlegm and moving stasis, regulating the flow of Qi to open what is depressed, clearing heat and resolving toxin, harmonizing the Ying and Wei etc..  For every aspect of the disease, one can select an appropriate methodology.  4) One is able to comprehensively regulate a patient’s Zang fu dynamic and promote balance of Yin & Yang. 

 3.2 Herbal method application:  Aim at specific characteristics of CFS pathology.  In clinic, the governing treatment principles I choose are to correct what is upright, to resolve toxin, and to regulate the Qi mechanism.  Consider using Huang Jing, Huang Qi, Bai Shao, Dang Gui, Sheng Di, Mai Dong, Yu Rou (Shan Zhu Yu),  Zhu Ru, Bai He, Nu Zhen Zi, Han Lian, all of which boost  and support the upright, supplement the Yin and harmonize the blood.  Among these it is appropriate to use Huang Jing in large doses. Combine these with Pei Lan, Chuan Po (Hou Po), Chen Pi, Fu Ling, Shen Qu, Sha Ren to move the Spleen and Stomach and move stagnation.  Chai Hu, Qin Jiao, Bai Hua She She  Cao, Yin Hua Teng (Ren Dong Tang), Si Gua Lou, and Mu Gua.  These course the wind and disperse evil, disinhibit damp, transform turbdity and resolve toxin.  Additionally one can modify depending upon the disease presentation.  If deficient heat is present add Di Gu Pi, Yin Chai Hu, Zhi Mu. For insomnia add He Huan Pi, Suan Zao Ren, Wu Wei Zi.  For dizziness add Gou Teng and Ju Hua.   I have treated many cases and obtained good treatment efficacy.