GERIATRICS IN CHINESE MEDICINE

The thinking about geriatrics in Chinese medicine has been dominated by Kidney deficiency for centuries. As Kidney-Jing declines as we age, the clinical approach to the treatment of the elderly has been based largely on tonifying the Kidneys.

However, modern diseases of the elderly that account for 90% of mortality (cancer, heart disease and stroke) are characterized by Fullness. Quite simply, we do not die of Kidney deficiency but of Phlegm, Blood stasis and Internal Wind.

The most common pathogenic factors (and those leading to serious diseases) are:
Phlegm
Blood stasis
Internal Wind

Apart from the major diseases of the elderly such as cancer, stroke and heart disease, very many symptoms and signs that occur in old age are caused by Phlegm and/or Blood stasis. The following is a partial list.

GERIATRIC SYMPTOMS/SIGNS
•Otosclerosis: Phlegm/Blood stasis
•Cataract: Phlegm
•Macular degeneration (vascular, lack of blood nourishment): Blood stasis
•Dry eyes: may be due to Blood stasis
•Alzheimer: Phlegm (the neurofibrillary tangles and plaques in the brain are a form of
Phlegm)
•Parkinson: Wind
•Poor memory: is often due to Phlegm
•Brain muzziness: Phlegm
•Dizziness: Phlegm
•Epiretinal membrane: Phlegm
•Macules: Blood stasis
•Dry skin: in the elderly may be due to Blood stasis
•Itching: Phlegm/Wind
•Numbness: Phlegm/Wind
•Hair loss: may be due to Blood stasis

The following three Tables list the major diseases of the elderly with the pathology they are due to:

Many of the symptoms of the elderly are due to Phlegm:
Heart: mental confusion, feeling of oppression in the chest
Gall-Bladder: stones, nausea, inability to digest fats
Joints: bone deformities, pain, rigidity
Lungs: cough with mucus, feeling of oppression of the chest, asthma, breathlessness
Stomach: lack of appetite, digestive problems, hiatus hernia, acid reflux.
Skin: greasy skin, sweating, yellow moles.

TONGUE DIAGNOSIS IN THE ELDERLY
This has already been discussed in a previous blog (April 2010). The major pathogenic factors of the elderly manifest on the tongue with the following signs:

Phlegm: swollen tongue body, sticky coating
Blood stasis: purple, stiff body
Internal Wind: stiff, moving deviated.

For example, if we see a tongue that is swollen, purple and stiff, it indicates all three pathogenic factors of Phlegm, Blood stasis and internal Wind. When I see a tongue like that in an elderly patient, I actively invigorate Blood and resolve Phlegm for prevention.

Purple (especially on sides) = Blood stasis
Stiff = internal Wind

Purple = Blood stasis
Swollen = Phlegm
Slightly Deviated = internal Wind

PULSE DIAGNOSIS IN THE ELDERLY

Pulse diagnosis in the elderly also reflects the fact that their clinical picture is dominated by Full conditions. In fact, in the elderly, the pulse is very often Full and Wiry and/or Slippery, not Weak.

TREATMENT PRINCIPLES IN DISEASES OF THE ELDERLY
Considering the above, I believe the most important treatment principles in the elderly are:
1) Invigorate Blood and eliminate stasis
2) Resolve Phlegm
3) Extinguish (internal) Wind

Some people think that eliminating pathogenic factors (with herbal medicine or acupuncture but especially with herbal medicine) may “weaken” the elderly. I have never found that to be true in practice: if an elderly person has Phlegm and Blood stasis, they will not be “weakened” by resolving Phlegm and invigorating Blood. Of course, one does need to adapt one’s doses to age so that dosages of herbs for the elderly should be lower than those for young people.

Invigorating Blood remedies: Red Stirring (Upper Burner), Stir Field of Elixir (Lower Burner), Harmonizing the Moon (Blood stasis in Uterus)
Resolving Phlegm remedies: Clear the Soul, Limpid Sea
Extinguishing Wind remedy: Clear Yang

Red Stirring = Xue Fu Zhu Yu Tang

Stir Field of Elixir = Ge Xia Zhu Yu Tang

Harmonizing the Moon = Gui Zhi Fu Ling Wan

Clear the Soul = Wen Dan Tang

Limpid Sea = Er Chen Tang

Clear Yang = Ban Xia Bai Zhu Tian Ma Tang

APPEAL TO EUROPEAN HERBAL PRACTITIONERS

I would like to remind all European herbal practitioners of the looming dangers of the European Union (EU) “Directive” called “Directive on Traditional Herbal Medicinal Products” (THMPD) coming into force in April 2011. This “directive” (note the Soviet-style sound of this word) is the greatest threat to herbal medicine. The EU Directive (formulated and enforced by the unelected and unaccountable European Commission) sets new over-the-counter (OTC) standards adopted in April 2004 with requirement for full implementation by April 2011. In the UK this will replace S12(2) of 1968 Medicines Act for OTC products (see below).

The Traditional Herbal Medicinal Products Directive (THMPD) comes fully into force in April 2011. After this time, only herbal medicines that have been registered under the scheme will be available EU-wide. For a wide range of herbal products, especially those from non-European traditions such as Ayurveda and traditional Chinese medicine, the requirements of the scheme are either impossible to meet or are prohibitively expensive. In many cases, both constraints apply so the result is that virtually no herbal medicines from these traditions have been registered. These products will effectively be banned after April 2011. The ban will also effect medicinal herbs in food supplements, which are used by many thousands of people across Europe to help maintain their health.

The Directive has the following aims:
- Aims to ensure correct identification of medicinal plants and adoption of Good Manufacturing Practice (GMP) by suppliers and manufacturers.
- Requires that OTC herbals demonstrate 30 years safe use for registration, 15 years of which within the EU.
- Monographing herbal safety and efficacy by the European Medicines Evaluation Agency Committee on Herbals.
- Permits limited medicinal claims on THMPD products

Problems with THMPD:
- Cost of licensing high.
- Cost of quality assurance also high.
- Quality control guidelines not workable for multi-herb complexes. This now has been recognised but now no applications for multi-herb complexes will be accepted until this is sorted out. The time for all this is running out as Section 12(2) products must be withdrawn from the market from April 2011 when the THMPD is fully implemented.

In the UK, herbal practitioners have been free to practise their art since the times of Henry VIII:
“Be it ordained established and enacted by authority of this present parliament, that at all time from henceforth, it shall be lawful to every person being the King’s subject, having knowledge and experience of the nature of Herbs, Roots and Waters… to practise, use and minister in, and to any outward swelling or Disease, any Herbs, Ointments, Baths, Pulters and Emplaisters, according to their Cunning, Experience and Knowledge … without suit, vexation, trouble, penalty or loss of their goods.”
The Herbalists’ Charter ordained by Henry VIII, 1543.

In 1968 the UK Medicines Act was enacted:
- Provides legal basis for the supply and sale of herbal medicines.
- Herbal medicines exempt from licensing.
- SI 2130 specifically allows powerful herbal medicines to be prescribed by herbalists.
- The term “herbalist” not defined.

The implementation of the EU THMPD would supercede this Act and would have particularly dire consequences from a medical, social, economic and political point of view as it would at a stroke abolish a freedom that has existed in England since 1543.

I therefore urge European herbal practitioners to support the organizations that are working very hard to oppose or at least mitigate the THMPD before April 2011.

European Herbal and Traditional Medicine Practitioners Association (EHPA): http://www.ehtpa.eu/

Association for Natural Health (ANH): http://www.anh-europe.org/

European Benefyt Foundation: http://www.benefyt.eu/

DAO DE JING
Chapter 30 (partial)
Whoever relies on the Tao in governing men
does not try to force issues
or defeat enemies by force of arms.
For every force there is a counterforce.
Violence, even well intentioned,
always rebounds upon oneself.

Chapter 60 (partial)
Governing a large country
is like frying a small fish.
You spoil it with too much poking.
Center your country in the Dao
and evil will have no power.

Chapter 75
When taxes are too high,
people go hungry.
When the government is too intrusive,
people lose their spirit.
Act for the people's benefit.
Trust them; leave them alone.

Translation by S Mitchell

Ear infections and antibiotics

A recent issue of the Journal of the American Medical Association carried an interesting article on the use of antibiotics for acute otitis media (AOM) or middle-ear infection. The reference is:
Tumaini R. Coker et al “Diagnosis, Microbial Epidemiology, and Antibiotic Treatment of Acute Otitis Media in Children” - A Systematic Review, in Journal of the American Medical Association, Vol. 304, No. 19, November 17, 2010, pp. 2161-2169.

The objective of the study was to perform a systematic review on AOM diagnosis and treatment with antibiotics. The study selected studies with a criterion standard, observational studies, randomized controlled trials on AOM microbiology and randomized controlled trials assessing antibiotic treatment.

The conclusion of the study was that antibiotics are modestly more effective than no treatment but cause adverse effects in 4% to 10% of children. Therefore, giving children antibiotics for ear infections does little to speed their recovery while raising the risk of some side effects.
The study found that 80 out of 100 otherwise healthy children would recover from an acute ear infection within a few days if given medication only to relieve pain or fever.

The study found that it does not matter which antibiotic is used to treat an ear infection when antibiotics are warranted. It found older types such as amoxicillin work as well as newer and more expensive antibiotics: indeed, newer antibiotics seem to cause more side-effects.

The study was designed to review existing research on the topic for the American Academy of Pediatrics, which is in the process of revising its guidelines for treating uncomplicated acute otitis media. The pediatricians’ group and the American Academy of Family Physicians have suggested that “observation” (i.e. avoiding antibiotics) is an option for treating ear infections in otherwise healthy children between the ages of 2 and 12. See http://aappolicy.aappublications.org/cgi/content/full/pediatrics;113/5/1451.

Of the three basic types of ear infections, acute otitis media may benefit from antibiotics because it is often caused by a bacteria. However, it can also be caused by a virus, which will not respond to antibiotics. Another type of ear infection, otitis media with effusion, causes a buildup of fluid in the middle ear. That is also caused by a viral infection, against which antibiotics are ineffective.

This is interesting from the perspective of Chinese medicine. I have observed over and over again in practice that antibiotic treatment seems to have little effect on ear infections (whilst, by contrast, they have some effect on chest infections). One obvious reason for this is that, as mentioned above, some ear infections may be viral. There may be another interesting reason. The ears are on the Shao Yang area of the body; indeed the Triple Burner and Gall-Bladder channels (Shao Yang channels) course around the ears. In the context of exterior diseases, i.e. diseases caused by external Wind, the Shao Yang stage behaves quite differently than the Tai Yang or Yang Ming stages. The Tai Yang stage is a purely exterior stage when Wind is located on the Exterior of the body, i.e. in the Wei portion. The Yang Ming stage, on the other hand, is an interior stage that occurs when the pathogenic factor has penetrated into the Interior and it has transformed into Heat.

The Shao Yang stage is quite different: it is the stage that is the “hinge” between the Exterior and the Interior. Because of this nature, pathogenic factors can get “stuck” in the Shao Yang stage, bouncing between the Exterior (Tai Yang) and the Interior (Yang Ming). When it is on the Exterior, the patient feels cold; when in the Interior, the patient feels hot: hence the famous “alternation of chills and fever” of the Shao Yang stage.

Another characteristic of the Shao Yang stage, and one that is related to its being the “hinge”, is that pathogenic factors can get “stuck” there and remain in the body for a long time. This cannot happen at the Tai Yang stage because, at this stage, either the Wind is expelled or it changes into Heat and penetrates in the Interior. At the Yang Ming stage too, the pathogenic factor is either cleared or it will injure Yin and it will penetrate into the Yin.

Because of the tendency of pathogenic factors to linger in the Shao Yang, this may be a cause for antibiotics not working and for middle-ear infections becoming chronic which, in children, they very frequently do. Moreover, the use of antibiotics may tend to injure the Stomach and lead to the formation of a residual pathogenic factor in the ears that is usually Damp-Heat. A residual pathogenic factor in the ear from the improper use of antibiotics is the most common cause of chronic ear pathology in children.

The remedy Ear Release in The Little Treasures was designed to treat chronic retention of Damp-Heat in the ears in children. See http://www.three-treasures.com/littletreasures/default.html

BL-22 SANJIAOSHU

Since the previous Clinical Tips were about the Swollen tongue and Phlegm, the use of acupuncture to resolve Dampness and Phlegm and the use of ST-40 to resolve Phlegm, I would like to stay with the subject of fluids pathology and discuss the use of the point BL-22 Sanjiaoshu.
I have mentioned this point in a previous entry as one of the points to resolve Dampness and/or Phlegm. BL-22 is called Sanjiaoshu, i.e. "Shu [point] of the San Jiao" and it is obviously situated just above BL-23 Shenshu, the Back-Shu point of the Kidneys: as we shall see below, this is very significant.
Given that the Triple Burner is an Arm channel, i.e. Arm Shao Yang, and therefore a channel of the upper limbs, why should the Back-Shu point of the Triple Burner be in the lower back near the kidneys and not in the upper back?
The book "An Explanation of Acupuncture Points" (1654) has a very interesting observation. It says that the Pericardium (Arm Jue Yin) has a Back-Shu point at BL-14 Jueyinshu (in the upper back) and the Triple Burner has a Back-Shu point at BL-22 Sanjiaoshu. Notice how the Pericardium has a Back-Shu point in the upper back (not by chance just above the Heart Back-Shu point BL-15 Xinshu) and the Triple Burner has its Back-Shu point at BL-22 Sanjiaoshu in the lower back, just above the Kidney's Back-Shu point BL-23 Shenshu (Fig. 1). "Logically" as the Triple Burner channels is associated with the Pericardium channel, the Triple Burner's Back-Shu point should be in the upper back also because the Triple Burner is an Arm channel (Arm Shao Yang). We shall soon see why it is in the lower back, just above the Kidney's Back-Shu point.







To explain why the Triple Burner Back-Shu point is next to the Kidney's we need to explore the nature of the Triple Burner. The Triple Burner's nature has occupied Chinese doctors for centuries and there are different views of it; as usual in Chinese medicine, different view are contrasting but not necessarily mutually-exclusive ones. For centuries, Chinese doctors have been discussing whether the Triple Burner "has a form" (you xing) or not. The Chinese expression "has a form" means that the Triple Burner is an actual Fu organ; if the Triple Burner "has no form", then it is not like the other Fu but just a complex of functions "without form". Both these views are correct!
Chapter 38 of the Nan Jing has the famous statement that the Triple Burner "you ming er wu you xing", i.e. it "has a name but not a form". The Chinese expression is very elegant in that it contrasts you (it has) with wu you (has no, it does not have) and also rhymes ming (name) with xing (form). Therefore according to the Nan Jing, the Triple Burner has no physical entity like the other Fu organs but it is a set of functions.
What are the main functions of the Triple Burner in the Nan Jing? Chapter 8 discusses the function of the Triple Burner: "This Yuan Qi is the root of the 12 channels, it is the Motive Force (Dong Qi 动 气) between the Kidneys, the root of the 5 Zang and 6 Fu and of the 12 channels, the gate of breathing and the origin of the Triple Burner."
Chapter 66 of the Nan Jing further explains the function of the Triple Burner and it is the origin of the famous view of the Triple Burner as the "envoy" of the Yuan Qi. It says: "Below the umbilicus and between the kidneys there is a Throbbing Qi [Dong Qi 动 气] which constitutes a person’s life [sheng ming 生 命]. This [Throbbing Qi] is the root of the 12 channels, also called Yuan Qi [原 气]. The Triple Burner is the envoy of the Yuan Qi [or it allows the Yuan Qi to separate into its different functions]." Figure 2 illustrates this passage.

This is a very important statement that links the Triple Burner not only with the Yuan Qi but also with the Ming Men which is called also the "Minister Fire". It may be because of this that the Triple Burner is said to belong to the “Minister Fire”. The Minister Fire is the physiological Fire of the Kidneys that is essential to all the Zangfu and all physiological processes. It is in the Kidneys but it comes out of the Kidneys through the intermediary of the Triple Burner and that is why the Triple Burner's Back-Shu point is not by chance above BL-23 Shenshu, the Back-Shu point of the Kidneys (Fig. 3).

Notice that I have two different translations of a crucial few words above, i.e. either "the Triple Burner is the envoy of the Yuan Qi" or "it allows the Yuan Qi to separate into its different functions". This second translation was proposed by Steve Clavey and it is one that has great merit. This interpretation means that the Triple Burner allows the Yuan Qi to separate into its different forms in different parts of the body to perform is various functions. The places where the Qi of the Yuan Qi "comes to a halt" are the Yuan points on each channel.
There is another interesting significant symmetry in the location of points and that is the one between BL-22 Sanjiaoshu and Ren-5 Shimen. BL-22 is the Back-Shu point of the Triple Burner and is above BL-23 Shenshu (Kidney’s Back-Shu); Ren-5 is the Front-Mu point of the Triple Burner and is above Ren-4 Guanyuan (a point closely related to the Kidneys). Note that Ren-5 also tonifies the Yuan Qi.
Thus, the location of BL-22 just above BL-23 and of Ren-5 just above Ren-4 (a point that tonifies the Kidneys and is related to Jing) confirms the above view of the Triple Burner as the agent allowing the Original Qi to emerge from between the Kidneys and be activated all over the body to perform its various functions. In practice, I often do use both these points (BL-22 and Ren-5) to stimulate the Triple Burner’s metabolism of fluids.
But going back to the point BL-22 what are its functions? I had the rather lengthy introduction above because some of its functions are related to the Triple Burner's being the "envoy" of the Yuan Qi. We could also call it the “agent” of the Yuan Qi.
The ancient book "An Explanation of the Acupuncture Points" mentioned above breaks down the actions of the point BL-22 according to Upper, Middle and Lower Burner.
- Upper Burner: headache from invasion of Wind-Cold, vomiting and rebellious Qi with digestive symptoms and dizziness.
- Middle Burner: (substantial) masses of the internal organs, a feeling of distension and fullness with emaciation, no appetite, shoulder pain, backache with rigidity.
- Lower Burner: turbidity, diarrhoea, abdominal distension, borborygmi.
Modern books lists more symptoms and these can be found in Deadman and Al Khafaji's "Manual of Acupuncture" (p. 282) and my own "The Channels of Acupuncture" (p. 984-5). Among the indications, modern books mention also the Shao Yang Syndrome, i.e. alternation of chills and fever, bitter taste, dry throat, etc.
From what I can see the old texts do not mention these indications under BL-22; for example, the Compendium of Acupuncture (Zhen Jiu Da Cheng) and the ABC of Acupuncture (Jia Yi Jing) do not mention it. I suspect this is a modern addition inspired by BL-22 being the Back-Shu point of the Triple Burner. However, and this is an important point, the "Triple Burner" that is the "agent" of the Yuan Qi and the Triple Burner as Water passages have nothing to do with the Triple Burner as the Shao Yang channel! In other words, there is an apparent dichotomy between the Triple Burner as the agent of the Yuan Qi and the Triple Burner as the Shao Yang channel. Thus, to treat the Shao Yang Syndrome I would definitely use points from Triple Burner channel and particularly T.B.-5 Waiguan and not BL-22.
Modern books list also oedema, difficult urination, turbid urine, blood in the urine and these indications are indeed also in the old texts. I personally use this point almost exclusively for the Lower Burner and especially to promote the transformation, transportation and excretion of fluids in the Lower Burner, hence the symptoms of oedema, difficult urination and turbid urine. I use this point in all cases of Dampness or Phlegm in the Lower Burner in combinations that I posted on an earlier blog and a previous Clinical Tip.
But another reason why this point would act on the fluids of the Lower Burner is to do with its function with regard to the Minister Fire of the Kidneys. Just like it is the "envoy" of the Yuan Qi, it is also the envoy of the Minister Fire. The Minister Fire heats the fluids in the Lower Burner and this (physiological) heat is essential to the transformation, transportation and excretion of fluids.
Thus, the point BL-22 acts on the fluids metabolism in the Lower Burner for two reasons. Firstly, the point transforms fluids and therefore resolves Dampness because the Triple Burner is a system of waterways for the transformation, transportation and excretion of fluids. The famous chapter 8 that compares the Zangfu to “officials” says that the Triple Burner is the official in charge “of irrigation and controls the Water passages”. Secondly, the point transforms fluids through its activation of the Yuan Qi and of the Minister Fire.
Thus, as the Triple Burner’s Back-Shu point is on the Bladder channel, there is a connection between these two channels. Interestingly, there is another connection between the Triple Burner and the Bladder channels that is highlighted in the “ABC of Acupuncture” (Jia Yi Jing) by Huang Fu Mi. This connection occurs via the point BL-39 Weiyang which is the Lower He point of the Triple Burner. The He points of the Triple Burner, Small Intestine and Large Intestines (all Arm channels) are T.B.-10 Tianjing, S.I.-8 and L.I.-11 Quchi respectively. However, since the organs of these three channels are located in the Lower Burner, these three channels also have three so-called “Lower He” points which are BL-39 Weiyang for the Triple Burner, ST-37 Shangjuxu for the Large Intestine and ST-39 Xiajuxu for the Small Intestine.
The “ABC of Acupuncture” says that the point BL-39 Weiyang, Lower He point of the Triple Burner, is used for abdominal distension and pain with retention of urine. The text specifically says that this is a “Triple Burner disease” and this confirms the nature of the Triple Burner as a system of waterways for the transformation, transportation and excretion of fluids.
In conclusion, there are at least four aspects to the Triple Burner:
1) It is a system of waterways that transport and excrete fluids
2) It is the “envoy” of the Yuan Qi and Minister Fire
3) It is a system of “cavities” (not discussed here)
4) It is a Shao Yang channel that treats mostly problems of the Shao Yang area in the shoulder and head (especially ears) and also the Shao Yang Syndrome from the Shang Han Lun.

ST-40 Fenglong

The last Clinical Tip discussed the treatment of Dampness and Phlegm and it started with a reference to ST-40 Fenglong. It seems therefore appropriate now to discuss the clinical use of the point ST-40 Fenglong. As I said in the previous Clinical Tip, whenever I mention ST-40 in the course of my lectures, everybody associates it with resolving Phlegm. As we shall see, this point has many other extremely valuable actions.

ST-40's name Fenglong means "Abundant Bulge": this obviously refers to the bulge on the fibularis longus muscle where the point is situated. However, the word feng meaning "abundant" or "rich in" has also another meaning: it refers to the quality of the Yang Ming channels of being "rich in Qi and Blood".[i] Feng, therefore, refers to the quality of the Stomach channel of being rich in Qi and Blood and, because of this, to its use in invigorating the channels. ST-40 Fenglong is the Luo point of the Stomach channel and we shall see what relevance this has in the clinical use of the point.

The main actions of ST-40 Fenglong listed in modern Chinese books are:
a) Resolves Phlegm and Dampness
b) Opens the chest and subdues rebellious Qi
c) Promotes the descending of Lung-Qi and stops cough
d) Calms the Mind and opens the Mind's orifices
e) Invigorates the channels[ii]

The indications related to ST-40 grouped according to its function are as follows:
a) Feeling of oppression of the chest, profuse sputum, swelling of the face, dizziness, headache, swelling of the throat, feeling of heaviness of the body
b) and c) Cough with sputum, breathlessness, wheezing
d) Manic-depression [Dian Kuang], inappropriate laughter, inappropriate elation, desire to ascend to high places and sing, undress, and run around, mental restlessness, "seeing ghosts".
e) Loss of use of the lower legs, atrophy of muscles of the lower leg, difficulty in walking from Deficiency conditions.

This is a very important point since it is the point to resolve Phlegm in all its manifestations and in all parts of the body. However, as discussed in the previous Clinical Tip, this point would eliminate Phlegm only in combination with several other points.

It eliminates substantial Phlegm, such as profuse expectoration from the chest, Phlegm in the form of lumps, such as lumps under the skin, thyroid lumps and uterus lumps, and non-substantial Phlegm such as the one that clouds the Mind and obstructs the Mind's orifices causing mental disturbances or simply headache, dizziness and muzziness of the head. In all these cases this point should be needled with reducing method to resolve Phlegm.

I use the point ST-40 for asthma not so much for its Phlegm-eliminating effect but because it promotes the descending of Qi in the chest area: this point has a strong action on the chest and, for this reason, it has an effect on asthma together with points such as P-6 Neiguan and LU-7 Lieque.

This point's action on the chest is such that I use it also in muscular problems of the chest: for example, it is excellent to move Qi and make Qi descend when there is bruising of the chest and ribs from an accident: in such cases, I combine ST-40 with P-6 Neiguan. Another important action of this point is to calm the Mind, on which it has a profound effect. It can be used in all cases of anxiety, fears and phobias, not only if they are caused by misting of the Mind by Phlegm but also if they are caused by rebellious Qi. Indeed, in my opinion, the Phlegm-resolving effect of this point originally was specific in relation to mental illness, i.e. this point was used to eliminate Phlegm from the Heart's orifices causing mental illness.

Interestingly, the book "An Explanation of Acupuncture Points" (1624) does not make any mention of the effect of ST-40 in resolving Phlegm from the Lungs in Lung diseases, but it does mention the effect of this point in eliminating Phlegm from the Heart's orifices causing Kuang syndrome, i.e. the manic phase of bipolar disorder.

The Phlegm-resolving of this point should not be overemphasized overlooking its other functions. Apart from its use to resolve Phlegm, ST-40 can also be used to subdue rebellious Qi of the Stomach and Lungs when the person is very anxious, and the anxiety reflects on the Stomach function, with such symptoms as tightness of the epigastrium, a feeling of knot in the Stomach or, as some people say, a feeling of "butterflies in the stomach".
ST-40's quality of Luo point is important to understand some of its functions. It departs from ST-40 Fenglong 8 cun above the external malleolus, it flows up the leg and a branch joins with the Spleen channel, it then flows up the torso to the nape of the neck and head where it converges with the Qi of other channels, it then flows down to the throat.
The fact that the Luo channels flows to the neck where it "converges with the Qi of the other channels" makes it an important point to use for Bi Syndrome of the neck. If there is a Stomach disharmony and the patient suffers from chronic neckache, I use the point ST-40 bilaterally with reducing method.

Finally, some of ST-40's actions are also due to its being the Luo point that influences the Xu Li. Xu Li is the name for the Great Luo of the Stomach. The Great Luo of the Stomach is mentioned in chapter 18 of the Ling Shu: "The Great Luo channel of the Stomach is called Xu Li. It penetrates the diaphragm, it connects with the lungs and exits below the left breast. One can feel its pulsation by hand: it is the place where the Gathering Qi (Zong Qi) of the vessels [or channels] is situated."

Although the Ling Shu does not mention ST-40 in connection with the Xu Li channel, I do use ST-40 Fenglong to affect the Xu Li: as the Xu Li flows to lungs and heart and it influences the Zong Qi, I use ST-40 to affect the Xu Li and especially the heart when the pulse is irregular. In other words, ST-40 is an important point to affect the rate and rhythm of the heart.


END NOTES

[i] Yue Han Zhen 1990 An Explanation of the Acupuncture Points (Jing Xue Jie), People's Health Publishing Company, Beijing, p. 102. The book An Explanation of the Acupuncture Points was written in 1624.

[ii] Li Shi Zhen 1985 Clinical Application of Frequently-Used Acupuncture Points (Chang Yong Shu Xue Lin Chuang Fa Hui), People's Health Publishing Company, Beijing, p. 209.

Resolving Dampness and Phlegm with acupuncture

When I give lectures I often hear that "ST-40 resolves Phlegm": I wish! Resolving Phlegm involves much more than simply using ST-40. In order to resolve Dampness or Phlegm, it is necessary to activate the Three Burners.
The Triple Burner is described in the Nei Jing as the official in charge of irrigation: this means that the Triple Burner is responsible for the transformation, transportation and excretion of fluids in all parts of the body and all organs. This is one of the most important functions of the Triple Burner.
The terms used in Chinese in connection with the Triple Burner’s influence on the body fluids are often shu 疏 which means “free flow” and tong 通 which means “free passage”. Therefore the Triple Burner is like a system of canals and waterways to channel irrigation water through the proper fields and then out: this ensures that body fluids are transformed, transported and excreted properly.
The Triple Burner’s function in relation to body fluids is closely dependent on its function of controlling the transportation and penetration of Qi. The Triple Burner influences the ascending/descending and entering/exiting of Qi in the Qi Mechanism:
it is the coordinated and harmonized ascending/descending and entering/exiting of Qi in all organs and structures that ensures that the body fluids also ascend/descend and enter/exit in the proper way in all places. Essentially, the transformation and movement of fluids depends on Qi.
This whole process is called “Qi Transformation by the Triple Burner”: the result of the Qi transformation is the production of Nutritive-Qi, Defensive-Qi, Blood and Body Fluids. That is also why the Triple Burner is said to control “all kinds of Qi”. This sums up the way in which acupuncture can influence the transformation, transportation and excretion of fluids: it can only achieve this through Qi.
Herbal medicine resolves Dampness by using herbs which are actually diuretic (e.g. Fu Ling, Zhu Ling, Ze Xie, Yi Yi Ren, etc.); and it resolves Phlegm by using herbs that are drying (e.g. Ban Xia, Dan Nan Xing, etc.). Acupuncture can resolve Dampness or Phlegm only by regulating the ascending/descending and entering/exiting of Qi in the Qi Mechanism.
Secondly, one must resolve Dampness or Phlegm by regulating the fluid movement, transformation and excretion by the Triple Burner. In my experience, in order to do this, it is necessary to activate all three Burners which means that one should not hesitate to use more points than one would normally use. For example, to resolve Phlegm from the prostate (i.e. Lower Burner), I would use many points from the Lower Burner (listed in previous slide) plus some from the Upper and Middle Burner.
Please note that when we say that we need to “regulate the Triple Burner”, we do not do that by using Triple Burner points necessarily. Many points regulate the fluid metabolism by the Triple Burner and especially points on the Ren Mai: indeed these are the most important ones.

POINTS TO ACTIVATE WATER TRANSFORMATION BY THE THREE BURNERS
- Upper Burner: Du-26 Shuigou, Ren-17, LU-7, LI-4, LI-6, TB-4, TB-6
- Middle Burner: Ren-9 Shuifen, Ren-12, ST-22, Ren-11
- Lower Burner: ST-28 Shuidao, Ren-5, BL-22,, BL-39, SP-9, SP-6, KI-7.

T.B.-4 and BL-64 in combination move Qi in the Triple Burner and activate Water Passages.

NOTE: the three points in blue (Du-26 Shuigou, Ren-9 Shuifen and ST-28 Shuidao) activate the fluid transformation in each Burner. Shui means “water” and those points are therefore “Water Ditch”, “Water Separation” and “Water Passages” respectively. The points in red are strategic points on the Ren Mai that have the same function, Ren-17, Ren-9 and Ren-5 for the Upper, Middle and Lower Burner respectively. As we can see, Ren-9 pertains to both groups of points and that is why this point is such an important point for the metabolism of fluids and a point I would always use to resolve Dampness or Phlegm.
This means that when I resolve Dampness and Phlegm, I do not hesitate to use quite a lot of points to activate all three Burners but giving predominance to the points where the Dampness or Phlegm is situated. For example, if there is Phlegm in the Lower Burner (e.g. prostatic hyperplasia), I would use many points from the Lower Burner but also some from the Middle and Upper Burner. This is an example of such a point combination: Ren-3, BL-22, Ren-5, ST-28, SP-9, ST-40 (Lower Burner), Ren-9 (Middle Burner) and LU-7 (Upper Burner). With variations, this point combination could also be used for Phlegm in the Uterus.

Swollen tongue

I frequently hear that a Swollen tongue indicates Qi deficiency. It is not so! In my experience, a Swollen tongue indicates Phlegm. But let us start by describing it first. A tongue is "Swollen" when the whole body is larger than normal. Crucially, a Swollen tongue is also somewhat rounder than a normal tongue. In very severe cases of Swollen tongue, the tongue may be almost perfectly round.

Before describing the clinical significance of a Swollen tongue, let us look at the clinical significance of a Thin tongue (i.e. the opposite of a Swollen tongue). As we all know, a Thin tongue indicates a deficiency of fluids, which may be Blood (is the tongue is Pale) or Yin fluids (if the tongue lacks a coating). It follows, therefore, that a Swollen tongue, being the opposite of a thin tongue, indicates that there is an excess of fluids. These "excess" fluids are not normal fluids but the accumulation of pathological fluids, i.e. either Dampness or Phlegm. I personally relate the swelling of the tongue body more to Phlegm than to Dampness (the latter reflected more on the coating).

I attach huge importance to the Swollen tongue: indeed, if the tongue is very swollen, I relate that to Phlegm even in the absence of any other symptoms or signs. This is after all an important aspect of tongue diagnosis, i.e. its preventive value. If a patient presents with a Swollen tongue (as in the picture above) I definitely resolve Phlegm. Please note that resolving Phlegm will not only help any internal disease the patient might have but it would also lead to an improvement of a channel problem as Phlegm obstructs the channels.

Please note that a Swollen tongue may be without coating (we would normally expect a sticky coating). This is not at all unusual and it is seen frequently in the elderly: it simply means that there is both Phlegm and Yin deficiency.

With acupuncture, to resolve Phlegm I would use these essential points: LU-7, Ren-9, Ren-12, SP-6 and ST-40. Other points that may be added are: BL-22, Ren-5, ST-28, KI-7 depending on the type of Phlegm and symptoms.

CHEMOTHERAPY AND CHEMO-SUPPORT

It is now 16 years since the Three Treasures remedy Chemo-Support was introduced. This remedy aims at lessening the side-effects of chemotherapy by tonifying Qi and Yin, clearing Heat, resolving Dampness and allaying nausea and vomiting. It has been used by hundreds (if not thousands) of patients world-wide. The newsletter of Summer 2005 explains the use of Chemo-Support and this is the link:

http://www.three-treasures.com/newsletters/summer05.html

It is always disappointing to hear about oncologists that still advise their patients against taking Chemo-Support, even after I provide a list of ingredients with their pharmacological effect. One reason oncologists advise against taking this remedy is the "old chestnut" of the alleged conflict between chemotherapy agents and anti-oxidants. The theory behind their opposition is that chemotherapy works by oxidating cancer cells and therefore one does not want to do anything that would prevent that.

The Spring 2010 Newsletter on Chemotherapy and Anti-oxidants deals with this question and I will not repeat the arguments here. Suffice to say that it is far from proven that anti-oxidants interfere with chemotherapy: indeed there is some evidence that they may even work in synergy with it and lessen its side-effects. The link to the Spring 2010 Newsletter is as follows:

http://www.three-treasures.com/newsletters/spring10.html

The second question is; even IF anti-oxidants counteracted chemotherapy, does this apply to Chinese herbs, or at least to the herbs in Chemo-Support? Does the remedy contain anti-oxidants to a level that allegedly might counteract chemotherapy? The answer is an emphatic “No”. There is therefore no reason whatsoever to avoid taking Chemo-Support during chemotherapy.

It pains me to have to tell patients (who frequently write to me) that, if they really have misgivings about taking Chemo-Support, they should follow the advice of their oncologist. I also find it upsetting that, in this age of integrative medicine, an oncologist may know nothing about Chinese herbs and yet advise patients not to take them. I hear this all the time: “My oncologist said that he (or she) does not know anything about Chinese herbs and that therefore I should not take them.” I would have thought that it is their duty to inform themselves about Chinese herbs: anything less is poor care.

THE TONGUE IN THE ELDERLY

Tongue diagnosis plays a very important role in the prevention of disease especially in the elderly. Middle-aged and elderly patients often show abnormal signs on the tongue in the absence of any obvious disease.
Elderly people often suffer from Internal Wind, Blood stasis, Phlegm, Heat or Yin deficiency or a combination of these. For example, it is common to have Blood stasis with Phlegm; or Phlegm with Yin deficiency; or Internal Wind with Phlegm; or a combination of the above. In the elderly, Blood stasis and Phlegm are so common that there is a saying in Chinese medicine which states “In the elderly, when in doubt, invigorate Blood and resolve Phlegm”.
In such cases, the tongue often shows clear signs of these pathogenic factors and it therefore allows us to treat them before they give rise to disease.
In particular, stroke in the elderly usually derives from a complex pathology involving Internal Wind, Yin deficiency with Empty Heat, Phlegm, and Blood stasis. The tongue of the elderly often points to such a complex pathology years before they may get a stroke. Therefore, if I see a tongue with those signs in an elderly person, I take active steps to treat them.
An example of a complex pathology showing on the tongue would be as follows:

- Deviated, Moving, Stiff = Internal Wind
- Red without coating = Yin deficiency with Empty Heat
- Swollen tongue body, sticky coating = Phlegm
- Purple = Blood stasis

The tongue illustrated here is Reddish-Purple (Blood stasis with Heat), Deviated and Stiff (internal Wind), lacking a coating in the centre, Red body (Yin Xu with Empty Heat), Swollen (Phlegm).
The remedy Peaceful Sunset was formulated to treat such a complex pathology in the elderly.

STICKY AND SLIPPERY TONGUE COATING

STICKY AND SLIPPERY TONGUE COATING

There are two types of greasy coating: one is called ni 膩which I call "sticky"; the other is hua 滑 which I call "slippery". The sticky coating is more common than the slippery coating. Both types of coating share a common quality of being greasy. The main difference is that with the sticky coating the individual papillae can be seen, while the slippery coating is more greasy and oily so that individual papillae cannot be seen.

Also, the sticky coating is greasy but it adheres firmly to the tongue body; the slippery coating is more oily and seems to "slip" on the surface of the tongue. Another difference is that the sticky coating may be dry (an apparent contradiction but frequent) indicating Phlegm with Dryness of Phlegm-Heat. The slippery coating cannot be dry.

A possible way of visualizing the difference between these two is to imagine spreading a layer of butter on a toothbrush: if we spread it thickly and do not push it down the bristles of the toothbrush will be completely covered and will not be seen. If we spread the butter more thinly and press it down on the brush, the bristles will still look greasy but we can see them.
Both sticky and slippery coating may indicate either Dampness or Phlegm: the sticky coating more frequently indicates Phlegm, while the slippery coating more frequently indicates Dampness.

The tongue on the top right has a sticky coating. The tongue on the top left has a slippery coating on ths sides (while the coating in the central crack is sticky.

Chest and breast area on the tongue

The “chest” area is on the sides of the tongue, between the centre part and the tip.
The chest area reflects a pathology of three organs: heart, lungs or breast in women.
Changes in this area to look for are:
1) Changes in colour (usually purple or red)
2) Changes in body shape (usually swollen or with teeth marks)
3) Red points

The chest area reflects pathologies of the lungs, heart or breast but in a Western medical sense. A change in the chest area may involve a change in colour or body shape. How to differentiate when a change in the chest area indicates a problem of the lungs or heart or of the breasts in women? A change in the chest area indicates a pathology of the breast in women rather that of lungs/heart when:
- In the absence of an obvious lungs/heart pathology
- Especially when it is unilateral

Examples of lung pathology manifesting in the chest area are chronic asthma or chronic emphysema (in which case the chest area would be swollen and possibly purple). An example of heart pathology is chronic coronary heart disease (in which case the chest area would be purple). As the area on the sides between the centre and the tip reflects the condition of heart/ lungs/ breast, I shall call this the “chest area”.

Apart from a purple colour and a swelling, other possible changes in the chest area are teeth marks that are confined only to the chest area, red points or a peeling of the chest area.

- Teeth marks only in the chest area indicate usually a problem in the breast in women (possible carcinoma) occurring against a background of severe Qi deficiency
- Red points in the chest area indicate Toxic Heat in thelungs or breast
- A peeling (absence of coating) in the chest area indicates a possible problem in the breasts in women occurring against a background of Yin deficiency.

A purple colour in the breast area in women is a potentially serious sign as Blood stasis in the breast may cause cancer. If I see this sign is a woman without symptoms, I would still treat her for Blood stasis in the breast. If I see a woman after she had breast cancer and surgery, I carefully examine the breast area: if it is purple it is not a good sign; vice versa, if it is not purple, it is a good prognostic sign.

In conclusion, as far as the Heart is concerned, we can say that the tip reflects a pathology of the Heart in a Chinese sense, i.e. problems of the Shen, while the chest area reflects a pathology of the heart in a Western sense (e.g. coronary heart disease

SP-4 GONGSUN

The meaning of the name of the point SP-4 (Gong Sun) is the subject of much discussion. I have never been convinced by the translation of Gong Sun as "Grandfather-grandson" (or rather grandchild). Besides being the Luo point of the Spleen, SP-4 is also the master point of the Chong Mai.

Although the translation of Gong Sun as "grandfather-grandchild" is possible, I think there is at least another possible explanation. "Gong" may also mean "general" and "sun" may also mean "second-growth", i.e. the second growth of a plant after pruning later in the season (like a rose for example). Thus, Gong Sun may be translated as "general second growth". What is this second growth? In my opinion, it is the image of the smaller branches stemming from a central stem. This is the image of the Main channels - the main stem - and of the Luo channels which branch out from the Main channels. This image is consistent with the point SP-4 for two reasons: first, because it is a Luo point; secondly because the Chong Mai controls all Luo channels.

There is another connection between the "second growth" and this point's name. The term "Sun" is also the term used in the Nei Jing to indicate the Minute Luo channels, i.e. the small Luo channels that stem from the Luo channels themselves: thus, while the Luo channels branch off from the Main channels, the Sun Luo branch off from the Luo channels themselves (and they are smaller). Thus, Gong Sun may be translated as "General Sun channels": this translation also makes sense because the Chong Mai controls all Sun Luo channels too.

孙 SUN

Finally, there is another possible and easy translation. Gong Sun was also the family name of the Yellow Emperor and we can therefore interpret this point's name as a reference to the Yellow Emperor. This translation would also make sense because the Chong Mai is the "emperor" of the extraordinary vessels, because it is the centre of the energetic vortex created by them. In old times, the extraordinary vessels were compared to members of a family and the Chong Mai was the "father", i.e. the most important member (in a traditional, Confucian view of the family).

TRIPLE BURNER AND YUAN QI: BL-22 and Ren-5

The location of the points BL-22 Sanjiaoshu above BL-23 Shenshu and of Ren-5 Shimen above Ren-4 Guanyuan is interesting and it presents interesting parallels. This location can be understood only by reference to Chapter 66 of the Classic of Difficulties (Nan Jing). Chapter 66 of this text states: “The Original Qi is the Motive Force [Dong Qi] situated between the two kidneys, it is life-giving and it is the root of the 12 channels. The Triple Burner causes the Original Qi to differentiate [for its different uses around the body]; the Original Qi passes through the Three Burners and then spreads to the 5 Yin and 6 Yang organs and their channels.”1
According to this view, therefore, the Triple Burner is the “agent” of the Yuan Qi arising from between the kidneys. This aspect of the Triple Burner is related to its transformation and excretion of fluids: in order to transform fluids, the body needs the heat of Kidney-Yang and of the Yuan Qi and this, in turn, needs the agency of the Triple Burner to be activated in all parts of the body to transform fluids.
I shall review below the actions and indications of BL-22 Sanjiaoshu and of Ren-5 Shimen, but only those relevant to fluid transformation.

BL-22 SANJIAOSHU Triple Burner Back-Shu Point
a) Nature
Back-Shu point for the Triple Burner.

b) Actions
1. Resolves Dampness
2. Opens the Water passages in the Lower Burner
3. Regulates the Lesser Yang.

c) Indications
1. Oedema, difficult urination, turbid urine, blood in the urine
2. Alternation of feeling of heat and feeling of cold, headaches, dizziness, bitter taste.

d) Comments
BL-22 is a major point to stimulate the transformation, transportation and excretion of fluids in the Lower Burner. The Lower Burner keeps the Water passages open so that “dirty” fluids may be excreted. This point regulates this particular function of the Lower Burner and thus ensures that the Water passages are open, fluids are properly transformed and dirty fluids excreted.
By stimulating the transformation and excretion of fluids, it resolves Dampness in the Lower Burner and treats such symptoms as urinary retention, painful urination, oedema of the legs, and any other manifestation of Dampness in the Lower Burner.
The effect of this point on the Lesser Yang channels and Lesser Yang Pattern requires an explanation. The Triple Burner is like the “envoy” of the Original Qi (Yuan Qi) emerging from the space between the kidneys; put it differently, the Triple Burner helps the Original Qi to “differentiate” into its different aspects in different parts of the body. Chapter 66 of the “Classic of Difficulties” mentioned above discusses the connection between the Original Qi (in this chapter called Dong Qi, “Motive Force”) and the Triple Burner.
BL-22 is just above BL-23, Back-Transporting point of the Kidneys, so this is the area from where the Triple Burner helps the Original Qi to emerge from the Kidneys and spread to the Internal Organs. Because of its connection with the Triple Burner, this point can be used for the Lesser Yang Pattern.

REN-5 SHIMEN Stone Door
a) Nature
Front-Mu point of the Triple Burner.

b) Actions
1. Opens the Water passages and promotes the transformation and excretion of fluids in the Lower Burner.
2. Strengthens Original Qi.

c) Indications
1. Difficult urination, retention of urine, painful urination, dark urine, oedema, diarrhoea, genital itching, swelling of scrotum, swelling of vulva, swelling of penis

d) Comments
In order to understand the function of this point, one must recall the role of the Triple Burner in relation to Original Qi (Yuan Qi). The Original Qi arises from between the Kidneys and spreads to the 5 Yin and 6 Yang organs via the intermediary of the Triple Burner. Ren-5 is the Front Collecting (Mu) point of the Triple Burner and rouses the Original Qi to circulate to all the organs and channels. It can therefore be used to tonify Original Qi in persons with Kidney deficiency and a poor constitution.
Another important function of the Triple Burner (and specifically the Lower Burner) is to transform and excrete fluids, and to ensure that the Water passages of the Lower Burner are open. Ren-5 stimulates this function of the Triple Burner, and specifically the Lower Burner: its use is therefore indicated for oedema of the abdomen, urinary retention, difficult urination, diarrhoea or vaginal discharge.

CONCLUSION
In conclusion, the location of BL-22 just above BL-23 and of Ren-5 just above Ren-4 (a point that tonifies the Kidneys and is related to Jing confirms the above view of the Triple Burner as the agent allowing the Original Qi to emerge from between the Kidneys and be activated all over the body to perform its various functions.

1. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi), p. 164. People’s Health Publishing House, Beijing, first published c. AD 100.

Spleen-Yin deficiency

It is often said that the Spleen can suffer only from Yang deficiency: it is true that this is a very common pathology of the Spleen but not the only one. Indeed, the Spleen can suffer from Yin deficiency.

A deficiency of Spleen-Yin does not usually occur on its own but it is associated with Stomach-Yin deficiency. Therefore, the symptoms of Spleen-Yin deficiency resemble those of Stomach-Yin deficiency (a dry mouth with desire to sip liquids, slight epigastric pain, tongue without coating). In addition to these, the symptoms of Spleen-Yin deficiency are dry lips and dry stools. There are particular cracks on the tongue that are typical of Spleen-Yin deficiency: these are small, transversal cracks on the sides (see picture). The formula to nourish Spleen-Yin is sha Shen Mai Dong Tang. If the Spleen-Yin deficiency is mild, Shen Ling Bai Zhu San may be used.