Myalgic Encephalomyelitis (ME)
By Giovanni Maciocia
Myalgic encephalomyelitis (ME) is becoming more and more widespread in Western countries. ME is the name most commonly used in the UK, while in the USA it is now called Chronic Fatigue Immune Dysfunction Syndrome (CFIDS). This condition is also variously called “Chronic Fatigue Syndrome,” “Postviral Syndrome,” or “Postviral Fatigue Syndrome.” I personally make a distinction between “true” ME and “not true” ME which I call “Postviral Fatigue Syndrome,” and this distinction (and its significance) will be explained shortly.
ME is still not generally accepted or recognized as a “disease” in Western medicine. The main reasons for this are that there is no accepted test for it and that the same condition may result from a number of different causative factors (e.g. enteroviruses, Epstein-Barr virus, etc.). However, several doctors are researching the aetiology and pathology of ME. In Britain, there seems to be general agreement among those who are researching ME that it is a chronic viral infection. The virus implicated is thought to be a Coxsackie virus, which belongs to the family of enteroviruses. Other researchers think that all the enteroviruses discovered in the last 30-40 years, of which there are 72, are no more than variations of the polio virus, and they believe that ME is nothing but a form of polio. In the acute stage, enteroviruses cause a fever and swollen glands; if not neutralized by the body’s immune system, they cause a chest infection and then settle in the intestines where they form a reservoir of infection (hence their name, as entero stands for “intestines”). From the intestines, these viruses display a particular tropism towards nerve and muscle cells therefore settling in the muscles and brain: this explains two of the major symptoms of ME, i.e. poor memory and concentration, and muscle ache. Muscle biopsy samples of 140 patients with clinical symptoms of ME showed that 24% of subjects were positive for the presence of enterovirus RNA. This may not sound like a high percentage but it becomes very significant when compared with a control group of 152 subjects, none of whom showed the presence of enterovirus RNA in their muscle biopsies. Statistically, this is a highly significant finding as P=<0.00001. In the USA, research seems to be oriented more towards the Epstein-Barr virus (the one that causes mononucleosis or glandular fever) as a cause of ME.
From the point of view of Chinese medicine, two main conditions explain the pathogenesis of ME: residual pathogenic factor and Latent Heat.
Residual pathogenic factor
One of the main conditions leading to ME 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 (usually as either Heat, Phlegm-Heat or Damp-Heat). Here, on the one hand, it continues to produce symptoms and signs and, on the other, it predisposes the person to further invasions of exterior pathogenic factors because it obstructs the proper diffusing and descending of Lung-Qi. Moreover, it will also tend to weaken Qi and/or Yin, establishing a vicious circle of pathogenic factor and deficiency.
Apart from Heat itself, Damp-Heat is a very frequent residual pathogenic factor after a febrile disease. There are two main reasons for this. First of all, in the course of a febrile disease, the ascending and descending movements of Spleen and Stomach are upset. Thus, because Stomach-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. Secondly, Heat burns the body fluids which can then condense into Dampness. Once formed, Dampness tends to be self-perpetuating. In fact, Dampness impairs the Spleen transformation and transportation which in itself leads to more Dampness being formed, thus establishing a vicious circle.
Antibiotics are one of the most common causes of residual pathogenic factor in our society. Whilst they do destroy bacteria, from the point of view of Chinese medicine they tend to “lock” the pathogenic factor into the Interior and do not release the Exterior in the beginning stages of an exterior invasion, nor do they clear Heat or resolve Phlegm in the later stages.
Symptoms of ME appearing without an acute infection can be explained as a manifestation of Latent Heat. The “Simple Questions” in chapter 3 says: “If Cold enters the body in wintertime, it comes out as Heat in springtime.” 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; this Heat later emerges, moving towards the Exterior and causing a person to feel a sudden onset of great weariness with dragging limbs and a slight thirst. The patient feels hot and irritable, does not sleep well and passes dark urine. At this time the pulse feels Fine and slightly Rapid and the tongue is Red. This condition, called Latent Heat, is also known as Spring Heat, although it can occur in any season, not just in springtime.
Besides causing the above symptoms and signs, Latent Heat also tends to injure Qi and/or Yin, thus establishing a vicious circle of Heat and deficiency. In the case of ME, Latent Heat usually takes the form of Damp-Heat. This process, the “incubation” of an exterior pathogenic factor in the Interior to emerge as Heat later, explains many cases of ME Latent Heat may move outward to emerge on the surface by itself, as described above; alternatively, it may be “pulled” towards the surface by a new invasion of external Wind, in which case, in addition to the above symptoms of interior Heat, there would also be some exterior symptoms such as shivering, fever, occipital headache, aches and sneezing. The pulse (Fine and Rapid) and tongue (Red), however, clearly point to interior Heat.
Another factor that may draw Latent Heat towards the surface is emotional stress. This may pull Latent Heat outwards, especially when it affects the Liver and causes Heat.
Thus Latent Heat occurs when an individual suffers an invasion of exterior Wind without developing immediate symptoms and the pathogenic factor remaining in the Interior turns into Heat that 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. The Wind penetrates the Interior without the person developing exterior symptoms; once in the Interior, it incubates and turns into Heat, which comes out some months later.
The ancient doctors believed in particular 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.” This concept is very important in practice as it implies that resistance to pathogenic factors depends not only on Lung-Qi (which influences Defensive Qi), but also on Kidney-Qi and Kidney-Essence. In fact, Defensive Qi is spread by the Lungs but it has its root in the Kidneys, specifically Kidney-Yang. Moreover, in chronic, recurrent infections such as ME, Kidney-Qi is very often deficient, leading to a decreased immune response.
Another possible cause of Latent Heat can be immunizations, when attenuated or inert forms of certain pathogenic organisms are injected into the body, by- passing the body’s first line of resistance. From a Chinese medical perspective it is as if an external pathogenic factor penetrated the body’s Interior directly, completely by-passing the Exterior levels. From the perspective of the Four Levels, immunizations consist in injecting a pathogenic factor (albeit attenuated) directly at the Blood level.
Latent Heat can also take the form of the Lesser Yang (Shao Yang) syndrome, characterized by alternation of shivers and feeling of heat, when the pathogenic factor is “trapped” between the Interior and Exterior: for this reason, when it goes towards the Exterior the person feels cold, when it goes towards the Interior the person feels hot. This pattern is more common in teenagers and young people.
In all the above conditions the underlying cause is overexertion and lack of adequate rest as explained above.
To summarize, three factors can give rise to ME:
A residual pathogenic factor (usually Damp-Heat) after an invasion of an exterior pathogenic factor
Latent Heat (usually also as Damp-Heat)
Lesser Yang pattern (in itself a form of Latent Heat)
The four groups of symptoms that are, in my opinion, essential to diagnose ME are:
Poor memory and inability to concentrate to the point of forgetting words while speaking, a feeling of “muzziness” of the brain
A persistent and intermittent flu-like feeling with shivers, sensations of heat, sore throat, swollen glands
Muscle ache and fatigue after the slightest exercise
I personally consider these to be the essential manifestations of what I call “true” ME, by which I mean one characterized by a persistent, chronic viral infection. If one or more of these four groups of symptoms are absent, I call the condition “not true” ME or simply “Postviral Fatigue Syndrome”, i.e. a state of fatigue following an acute febrile disease but without a persistent viral infection. Although the aetiology, pathology and treatment of ME and Postviral Fatigue Syndrome are exactly the same, I believe this distinction is important for prognosis as “true” ME is much more difficult to treat and will take longer to respond to treatment.
As for the muscle ache, from the Chinese point of view it is directly related to Dampness: the more Dampness there is, the greater the muscle ache, and vice versa. From a Western perspective, I relate the muscle ache intensity to the viral infection.
Every case of ME is characterized by both a Deficiency (of Qi, Yang, or Yin) and a Fullness (usually Dampness or Damp-Heat). However, the Deficiency and the Excess are never absolutely equal as one always predominates. If Deficiency predominates, one must tonify; if Fullness predominates, one must expel Dampness. The pulse and the tongue are essential diagnostic factors to distinguish between a Deficiency condition and an Excess condition. If the pulse is Full and Slippery and the tongue has a thick coating, Excess predominates; if the pulse is Weak or Fine and the tongue has no thick coating, Deficiency predominates. From the point of view of symptoms, the more muscle ache there is, the more the condition is one of Fullness. One cannot differentiate between a Deficiency condition and an Excess condition purely on the grounds of tiredness.
Table #1: Differentiation between Deficiency and Excess in ME
SYMPTOMS TONGUE PULSE
DEFICIENCY No or little muscle ache, no pronounced flu- like feeling Thin coating, not too Swollen Weak, Choppy or Fine
EXCESS Pronounced muscle ache and flu-like feeling Thick coating, Swollen Full, Slippery or Wiry
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