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.

PHLEGM - BLOOD STASIS - WIND
Heart disease √ √
Angina √ √
Arteriosclerosis √ √
Thrombosis √
Atheroma √
Hypertension √ √ √

PHLEGM BLOOD STASIS WIND
Stroke √ √ √
Cholesterol √
Chronic bronchitis √
Cancer √ √
Diabetes √ √
Chronic nephritis √

PHLEGM BLOOD STASIS WIND
Prostatic hypertrophy/cancer √ √
Parkinson √
Alzheimer √ √
Trigeminal neuralgia √
Dizziness √ √

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.

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.

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.

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.