Chapter contents

INTRODUCTION

This is not one of the traditional 10 questions of Chinese diagnosis. I have added it to the list of questions because tiredness is one of the most common symptoms reported by Western patients. In my practice, about 12% of patients seek treatment specifically and only for tiredness; and to these should be added all the other patients who come for other symptoms or diseases but who also suffer from chronic tiredness.

WHY WE ASK

It is always essential to ask about level of energy and tiredness because it is such a common complaint: indeed, it is often the main reason that patients seek treatment.

WHEN WE ASK

I generally ask about tiredness quite early during the interrogation and as soon as I suspect a Deficiency pattern.

HOW WE ASK

This is generally quite straightforward and I usually ask whether they ‘feel unusually tired’ or whether they ‘lack energy’. However, when enquiring about tiredness, it is very important to enquire about the patient’s lifestyle. Many people have unrealistic expectations about their level of energy. If people in industrialized societies work too much and for far too long, a feeling of tiredness is entirely normal. For example, it is not uncommon for someone to get up at 6 am, leave home at 6.30 to catch a train, work the whole day under hectic conditions (having a sandwich at the desk for ‘lunch’) and return home at 9 in the evening; such a schedule is precisely what constitutes ‘overwork’ in Chinese medicine.

Our level of energy depends also on age. Again, very many people have unrealistic expectations about their desired level of energy and are surprised that they cannot do at 55 what they did when they were 25.

HISTORICAL BACKGROUND

There is no Chinese disease-symptom category called ‘tiredness’ but there is one called ‘exhaustion’ (Xu Lao or Xu Sun). The term Xu Lao describes not only a symptom, that is, ‘tiredness’ (Lao) but also its pathology, that is, a deficiency of the body’s Qi (xu). The term Xu Lao was introduced in the ‘Prescriptions from the Golden Cabinet’ for the first time. It says in Chapter 6: ‘When the pulse is big but empty in male patients, it indicates extreme exhaustion from over-exertion.’¹

The ‘Discussion on the Causes and Symptoms of Diseases’ (Zhu Bing Yuan Hou Lun, AD610) by Chao Yuan Fang elaborates on the concept of exhaustion by investigating its causes. Dr Chao considers exhaustion to be due to the ‘6 Excesses’ (overexertion leading to depletion of Qi, Blood, Sinews, Bones, Muscles and Essence) and the ‘7 Injuries’. The ‘7 Injuries’ refer to the damage inflicted on the Internal Organs by various excesses such as:

The ‘Simple Questions’ in Chapter 23 lists five causes of exhaustion:

Over the centuries various doctors discussed the treatment of exhaustion according to their particular views and emphases. For example, Li Dong Yuan, author of the famous ‘Discussion on Stomach and Spleen’ (Pi Wei Lun, 1249),⁴ considered Stomach and Spleen deficiency to be the main cause of exhaustion. Zhu Dan Xi, author of ‘Secrets of Dan Xi’ (Dan Xi Xin Fa, 1347),⁵ placed the emphasis on Kidney- and Liver-Yin deficiency as a cause of exhaustion and advocated nourishing Yin and clearing Heat. Zhang Jie Bin, author of the ‘Classic of Categories’ (Lei Jing, 1624)⁶ and the ‘Complete Book of Jing Yue’ (Jing Yue Quan Shu, 1624),⁷ advocated tonifying the Kidneys for the treatment of exhaustion.

Zhu Qi Shi (1463–1539) considered the Lungs, Spleen and Kidneys to be the three most important organs to treat in exhaustion. He said in his book ‘Discussion on Exhaustion’ (Xu Lao Lun): ‘To treat Exhaustion there are three roots: Lungs, Spleen and Kidneys. Lungs are like the “heaven” of the internal organs, the Spleen is like the “mother” of the body and the Kidneys are like the “root” of life. Treat these three organs to treat Exhaustion.’⁸ Dr Zhu indicated the Spleen and Lungs as the two main organs to treat in cases of chronic tiredness, the Spleen for Yang deficiency and the Lungs for Yin deficiency. Each of these can eventually lead to Kidney-Yang or Kidney-Yin deficiency and Yang deficiency can lead to Yin deficiency, or vice versa. Dr Zhu says: ‘To treat Deficiency there are two interconnected systems: either the Lungs or the Spleen. Every [Deficiency] disease boils down to Yang or Yin deficiency. Yang deficiency can lead to Yin deficiency after a prolonged time. Yin deficiency can lead to Yang deficiency after a prolonged time. In Yang deficiency treat the Spleen, in Yin deficiency treat the Lungs.’⁹

Thus, tiredness is included in the concept of exhaustion, although the latter is a more serious condition than simple tiredness. However, although exhaustion contemplates only Deficiency causes, tiredness may also be due to Full causes; Dampness, Phlegm and Qi stagnation are common causes of tiredness.

PATTERNS CAUSING TIREDNESS

A chronic feeling of tiredness is usually due to Deficiency. This may be Qi, Yang, Blood or Yin deficiency. In some cases, tiredness may also be due to a Full condition, and especially Dampness, Phlegm or Qi stagnation.

The pulse is an important sign to differentiate Full from Empty types of tiredness: if the pulse is Full in general (often Slippery or Wiry) it indicates that the tiredness is caused by a Full condition (usually Dampness, Phlegm or Qi stagnation).

Dampness and Phlegm are ‘heavy’ and weigh down the body so that the person feels heavy and tired. Qi stagnation may also make a person feel tired; this is not because there is not enough Qi but because, being stagnant, Qi does not circulate properly. This situation is more common in men and it often reflects a state of mental depression. The classic example would be that of a man who seeks treatment primarily for tiredness and whose pulse and tongue reveal no Deficiency at all but only severe Qi stagnation, the pulse being very Wiry and Full on all positions and the tongue being Red on the sides. In such a situation the man feels tired from Qi stagnation and his tiredness is closely linked to a state of mental depression (itself often deriving from repressed anger).

Chronic tiredness associated with a desire to lie down, poor appetite and loose stools indicates Spleen-Qi deficiency, which is probably the most common cause of it; if there are Cold symptoms, it is due to Spleen-Yang deficiency.

Chronic tiredness associated with a weak voice and a propensity to catching colds indicates Lung-Qi deficiency; if there are Cold symptoms, it is due to Lung-Yang deficiency.

Chronic tiredness associated with backache, lassitude, a feeling of cold, depression and frequent urination indicates Kidney-Yang deficiency.

Chronic tiredness associated with slight depression, dizziness and scanty periods indicates Liver-Blood deficiency.

Chronic tiredness associated with anxiety, insomnia, a dry mouth at night and a tongue without coating is due to Kidney-Yin deficiency.

Chronic tiredness associated with a feeling of heaviness of the body and muzziness of the head indicates retention of Dampness.

Chronic tiredness associated with a feeling of oppression of the chest, dizziness and muzziness of the head indicates retention of Phlegm.

Chronic tiredness in an anxious and tense person with a Wiry pulse indicates stagnation of Liver-Qi.

Short-term tiredness with alternating cold and hot feeling, irritability, unilateral tongue coating and a Wiry pulse indicates the Lesser-Yang pattern (either of the Six Stages or of the Four Levels).

Case histories 33.1–33.7 illustrate different patterns causing tiredness.

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