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.

My favourite point: G.B.-13 Benshen Spirit Root

a) Nature
Point of the Yang Linking Vessel (Yang Wei Mai).
Meeting point of the 3 Yang Muscle channels of the arm.

b) Actions
- Calms the Mind (Shen) and settles the Ethereal Soul (Hin)
- Subdues Liver-Yang
- Extinguishes Wind
- Resolves Phlegm
- Gathers Essence (Jing) to the head
- Clears the brain.

c) Indications
Manic behaviour, fright
Headache, dizziness
Epilepsy, hemiplegia, convulsions
Vomiting of foamy saliva, epilepsy with foaming at the mouth.

d) Comments
G.B.-13 is a very important point for mental and emotional problems. It is very much used in psychiatric practice for schizophrenia and split personality combined with HE-5 Tongli and G.B.-38 Yangfu.1 It is also indicated when the person has persistent and unreasonable feelings of jealousy and suspicion.
Apart from these mental traits, it has a powerful effect in calming the Mind, settling the Ethereal Soul (Hun) and relieving anxiety deriving from constant worry and fixed thoughts. Its effect is enhanced if it is combined with Du-24 Shenting.
Its deep mental and emotional effect is also due to its action of “gathering” Essence (Jing) to the head. The Kidney-Essence is the root of our Pre-Heaven Qi and is the foundation for our mental and emotional life. A strong Essence is the fundamental prerequisite for a clear Mind (Shen) and a balanced emotional life. This is the meaning of this point's name “Root of the Spirit”, i.e. this point gathers the Essence which is the root of the Mind (Shen) and Spirit. The Kidney-Essence is the source of Marrow which fills up the Brain (called Sea of Marrow): G.B.-13 is a point where Essence and Marrow “gather”. The “Great Dictionary of Acupuncture” says that this point “makes the Mind [Shen] return to its root”2: the “root” of the Mind is the Essence, hence this point “gathers” the Essence to the Brain and affects the Mind. As it connects the Mind and the Essence, it also treats both the Heart and the Kidneys and therefore the Mind (Shen) and Will-Power (Zhi): for this reason, it is an important point in the treatment of depression.
When combined with other points to nourish Essence (such as Ren-4 Guangyuan), G.B.-13 attracts Essence towards the head with the effect of calming the Mind and strengthening clarity of mind, memory and will power. The connection between G.B.-13 and the Essence is confirmed by the text “An Enquiry into Chinese Acupuncture” which has among the indications of this point: “excessive menstrual bleeding, impotence and seminal emissions.”3
G.B.-13 also subdues Liver-Yang and it can therefore be used as a local point in chronic headaches from Liver-Yang rising. It also extinguishes internal Wind and is effective for Wind-stroke and epilepsy. Finally, it resolves Phlegm in the context of mental-emotional disorders or epilepsy, i.e. it opens the Mind's orifices when these are clouded by Phlegm. The “Explanation of the Acupuncture Points” says: “The indications of G.B.-13 show that it eliminates the three pathogenic factors of Wind, Fire and Phlegm from the Lesser Yang, in which cases this point should be reduced.”4

1. Dr Zhang Ming Jiu, personal communication, Nanjing 1982.
2. Cheng Bao Shu 1988 Great Dictionary of Acupuncture (Zhen Jiu Da Ci Dian), Beijing Science Publishing House, Beijing, p. 11.
3. Jiao Shun Fa 1987 An Enquiry into Chinese Acupuncture (Zhong Guo Zhen Jiu Qiu Zhen), Shanxi Science Publishing House, p. 52.
4. Yue Han Zhen 1990 An Explanation of the Acupuncture Points (Jing Xue Jie), People's Health Publishing House, Beijing. Originally published in 1654, p. 334.