Further information on Warm the Menses can be found at http://maciociaonline.blogspot.com.es/2015/02/focus-on-remedy-warm-menses.html

Empty Heat derives from Yin deficiency and the two pathological conditions (Yin deficiency and Empty Heat) are often considered as one.  All modern Chinese books include Empty Heat clinical manifestations under the patterns of Yin deficiency.  For example, under the pattern of Lung-Yin deficiency they will have dry throat and dry cough (Yin deficiency) and 5-palm heat (Empty Heat).

This is not the case in practice as Yin deficiency may last a long time without symptoms or signs of Empty Heat: thus, Yin deficiency and Empty Heat are two separate pathological conditions, even though, of course, the latter derives from the former.

The symptoms of Yin deficiency vary according to the organ involved but generally they will include night-sweating and symptoms and signs of dryness such as dry throat, dry cough, dry lips, dry eyes, dry mouth, thirst with desire to drink in small sips, tongue without coating possibly with cracks.

The symptoms and signs of Empty Heat will include feeling of heat (that is worse in the evening), 5-palm heat (a feeling of heat of palms, chest and soles of feet), malar flush, low-grade fever, a red tongue without coating and possibly a rapid pulse.

The tongue shows conditions of Yin deficiency and Empty Heat clearly.  It is important to understand that, although Empty Heat derives from Yin deficiency, it takes time for it to develop.  Therefore, a patient may display all the signs of Yin deficiency on the tongue for several years without developing Empty Heat and the tongue shows this clearly by lacking a coating (Yin deficiency) but being of a normal colour (no Empty Heat).


In fact, Yin deficiency manifests on the tongue with a lack of coating; therefore, a tongue without coating but of a normal body colour indicates Yin deficiency without Empty Heat. As Yin deficiency aggravates with time, Empty Heat may develop and this turns the tongue red: therefore Empty Heat on the tongue is manifested by a red body colour together with the absence of coating.  One often hears that “in Yin deficiency the tongue is red” (a statement that is tempting to make since “in Yang deficiency the tongue is pale”). This is not so: in Yin deficiency, the tongue lacks a coating; in Empty Heat, the tongue lacks a coating and it is red.

No coating, cracks, normal colour = Yin deficiency

No coating, deep red = Yin deficiency with Empty Heat

A tongue without coating indicates Yin deficiency first and foremost of the Stomach: in addition, it may also indicate Yin deficiency of the Kidneys, Liver or Heart.

That Yin deficiency can occur without Empty Heat is demonstrated by tongue diagnosis as many patients have a tongue that lacks a coating (indicating Yin deficiency) but is not red.

Yin deficiency and Empty Heat are not formed in a short space of time: it takes years from them to develop (the only exception is the Yin deficiency and Empty Heat that may form in an acute way during an invasion of Wind-Heat with Heat penetrating into the Interior). The tongue shows clearly not only the present condition but also the stage it is at: it therefore also shows where it is developing from and what it may lead to.



The three stages of the formation of Yin deficiency based on the tongue are:

1) Rootless coating (this is the mildest form of Yin deficiency)
2) Coating partially missing
3) Coating missing completely

Rootless coating = early stage of Yin deficiency

Coating partially missing

Coating missing completely

Coating missing completely, slightly red

 Empty Heat may develop at any of these stages but it is more likely to develop at the third when the tongue has no coating and it is red.

That Yin deficiency and Empty Heat are two separate pathological conditions is clear also from herbal medicine.  In fact, the herbs and formulae that nourish Yin are in a separate category than the herbs and formulae that clear Empty Heat.

For example, Mai Men Dong Tuber Ophiopogonis japonicis and Tian Men Dong Tuber Asparagi cochinchinensis nourish Yin but they do not clear Empty Heat.  Qin Jiao Radix Gentianae Qinjiao and Qing Hao Herba Artemisiae annuae clear Empty Heat.  When there is Empty Heat of course one combines herbs that clear Empty Heat with those that nourish Yin.

When giving my lectures I am often surprised by the fact that many practitioners do not use the Back-Shu points very much.  In this short article I would like to explain how I use the Back-Shu points in practice.

The Back-Shu points are mentioned in various chapters of the Nei Jing.  Chapter 51 of the "Ling Shu" lists the Back-Shu points of the five Zang.1 

Chapter 59 of the "Su Wen" discusses the Back-Shu points of the Fu; in all, the Nei Jing lists 10 Back-Shu points, leaving out BL-22 Sanjiaoshu, first mentioned in the "ABC of Acupuncture" (Jia Yi Jing, AD 282), and BL-14 Jueyinshu, first mentioned in the "1000 Golden Ducats Prescriptions" (Qian Jin Yao Fang, AD 652).2

The Chinese character (Shu 俞) denoting these points means “to transport” indicating that they transport Qi to the inner organs. Each point takes its name from the corresponding organ, e.g. BL-15 Xinshu is “Heart-Shu”. 

The importance of the Back-Shu points in treatment cannot be over-emphasized. They are particularly important for the treatment of chronic diseases and, indeed, one may go so far as saying that a chronic disease cannot be treated without using these points at some time during the course of treatment.  This is essentially how I use them, i.e. to tonify the organs (Yin or Yang) in chronic conditions. 

The Back-Shu points affect the organs directly and are therefore used in Interior diseases of the Yin or Yang organs.  This is a very important aspect of the clinical effect of these points.  The way in which they act is quite a different from that of other points.  

When treating the Internal Organs, other points work by stimulating the Qi of the channel which then flows along the channel like a wave, eventually reaching the Internal Organs.  For example, if we needle LIV-3 Taichong we initiate a small wave around the point that flows along the channel, eventually reaching the Liver.  If we needle BL-18 Ganshu (Back-Shu point of the Liver) we reach the organ directly without having to go through the channel.  

In my experience, when we needle the Back-Shu points, Qi goes directly to the relevant organ, not through the intermediary of its channel.  For this reason, I usually retain the needle in these points a shorter time than for other body points (usually no longer than 10 minutes when used to tonify).  That is because we do not have to wait for the “wave” in the channel to reach the organ. 

Chapter 67 of the “Nan Jing” says: “Yin diseases move to the Yang [area]; Yang diseases move to the Yin [area]. The Front-Mu points are situated on the Yin surface [and therefore treat Yang diseases]; the Back-Shu points are situated on the Yang surface [and therefore treat Yin diseases].”3  According to this statement, the Back-Shu points would be used to treat “Yin diseases” and the Front-Mu points “Yang diseases”.  “Yin diseases” and “Yang diseases” can be interpreted in different ways. 

One interpretation of “Yin” or “Yang diseases” is that of chronic and acute diseases respectively: in this interpretation, the Back-Shu points would be used for “Yin diseases”, i.e. chronic diseases, and the Front-Mu points for “Yang diseases”, i.e. acute diseases. 

Although this rule should not be interpreted rigidly, it is certainly valid and finds a widespread clinical application, i.e. using the Back-Shu points for chronic and the Front-Mu points for acute diseases. This is how I use them. 

Another characteristic of the Back-Shu points is that they are used to affect the sense organ of the corresponding organ. For example, BL-18 Ganshu is the Back-Shu point of the Liver and can be used for eye diseases.

Although the Back-Shu points are mostly used to tonify the organs, they can also be used in Full patterns. In particular, they can be used to subdue rebellious Qi and clear Heat. For example, the point BL-21 Weishu can be used to subdue rebellious Stomach-Qi in case of belching, nausea or vomiting. The point BL-18 Ganshu can be used to move stagnant Liver-Qi.  BL-15  Xinshu can be used to clear Heart-Fire and BL-13 Feishu to stimulate the diffusing and descending of Lung-Qi and release the Exterior.

I personally use the Back-Shu points after needling points on the front of the body.  I would usually retain the body points approximately 20 minutes (in an adult), withdraw them, ask the patient to turn over, and then use the Back-Shu points.  I generally leave the Back-Shu points in a shorter time, i.e. no longer than 10 minutes (in an adult).  I needle the Back-Shu points obliquely towards the midline.

If I use the Back-Shu points to tonify Qi, Yang or Blood, I often use direct moxa cones (7 moxa cones).

In conclusion, I personally think that using the Back-Shu points is essential to treat chronic diseases. 



END NOTES
1. 1981 Spiritual Axis (Ling Shu Jing). People’s Health Publishing House, Beijing, first published c. 100 BC. p. 100.

2.  1979 The Yellow Emperor’s Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen). People’s Health Publishing House, Beijing, first published c. 100 BC,  pp. 303-312.

3. Nanjing College of Traditional Chinese Medicine 1979 A Revised Explanation of the Classic of Difficulties (Nan Jing Jiao Shi). People’s Health Publishing House, Beijing, first published c. AD 100, p.  146.

I recently received an email from a colleague asking for a help with a patient suffering from chronic fatigue syndrome.  The colleague was asking about the treatment principle to apply.  The patient obviously suffered from a deficiency of Zheng Qi, as all patients with chronic fatigue syndrome do.  But she also had frequent acute invasions of Wind.

The colleague was rightly following the principle that, in the presence of an acute invasion of Wind, one must expel pathogenic factors, in this case expelling Wind, and not tonify Zheng Qi.  In between invasions of Wind, the correct treatment principle is to tonify Zheng Qi, and this what the colleague was doing.

However, the problem was that the patient suffered from very frequent invasions of Wind, so that there was hardly any time to tonify Zheng Qi for a prolonged time.  She was using Three Treasures remedies i.e.  Expel Wind-Heat (a variation of Yin Qiao San) during the acute invasions of Wind and Herbal Sentinel to tonify Zheng Qi in between the acute attacks.

She wrote to me to ask whether taking Herbal Sentinel (i.e. a Qi tonic) during an acute invasion of Wind could strengthen the pathogen.  She was also wondering whether one can go on taking Expel Wind-Heat for prolonged periods as the patient had times when she went from one acute illness to the next, so she could be taking Expel Wind-Heat for weeks, and my colleague was wondering whether this could deplete her Qi or Yin.

Her second question was whether taking Herbal Sentinel during an acute invasion of Wind could strengthen the pathogen.

I will try and answer here her questions.

1) Can one take a remedy that expels exterior Wind for prolonged periods?

The answer is basically: “no”.  Remedies that expel exterior Wind (such as Expel Wind-Heat or Yin Qiao San) by definition should be taken only during an acute invasion of Wind for a few days.  After a few days or a week, either the exterior Wind has been expelled or the pathogenic factor has penetrated into the Interior at which time the patient needs a different treatment.

However, chronic fatigue syndrome presents a different situation and one that is not contemplated in Chinese books.  I have never seen a discussion of chronic fatigue syndrome in any Chinese book: indeed, a Chinese journal years ago published a translation of an article I wrote on chronic fatigue syndrome.

In my experience, chronic fatigue syndrome is characterized by a prolonged course of the disease with deficiency of Zheng Qi and frequent invasions of exterior Wind.  However, the exterior pathogen in such patients is “weak” and it is weak precisely because of the prolonged course of the disease and the prolonged deficiency of Zheng Qi.

So, in such cases, the patient may need to take a remedy that expels exterior Wind frequently, e.g. for a week every few weeks or so.  However, because the pathogen is weak, one can use a small dose such as for example only three tablets of Expel Wind-Heat a day.

2) Can tonifying the Zheng Qi also tonify an exterior pathogen?

Again, in theory “yes”.  However, again, chronic fatigue syndrome is an exception.  As the deficiency of Zheng Qi is very prolonged and the pathogen “weak”, during invasions of exterior Wind in chronic fatigue syndrome, I do occasionally combine expelling exterior Wind with Expel Wind-Heat (Yin Qiao San) with Herbal Sentinel, both in small doses.  For example, I might use 3 tablets or Herbal Sentinel in the morning and 3 tablets of Expel Wind-Heat in the evening.

Note: Herbal Sentinel is a tonic of Lungs and Kidneys to strengthen Zheng Qi and prevent invasions of Wind.   There are two variations of it: Herbal Sentinel-Yang for patient with a tendency to Yang deficiency and  Herbal Sentinel-Yin for patients with a tendency to Yin deficiency.

For a discussion of Chronic Fatigue Syndrome see chapter 41 of my book The Practice of Chinese Medicine, 2nd Edition.

ARISTOLOCHIA: THE MALIGNANT LIE AND THE BENIGN TRUTH
Chris Dhaenens
Journal of the Register of Chinese Herbal Medicine (UK), Spring 2013, Vol. 10, no. 1.

This article was commissioned in response to a recent piece in the Lancet (Daniel Kell, Justin Stebbing. ‘Aristolochia: the malignant truth’) published under‘Quackery’ rubric, in www.thelancet.com/oncology/Vol 14 January 2013which revisits the aristolochia story. The trigger for this revisitation was a completely unrelated case of acute liver failure in a patient poisoned by arsenic oxide, contained in a remedy that she had been taking (the nature of the remedy is not specified). Arsenic, the authors note, is a "well known poison that has been linked to the death of several historical figures, including George III. Although we cannot discount the potential medicinal properties of many natural and alternative therapies...this case serves to highlight the potential dangers associated with the use of unlicensed or underevaluated products or their use without strict medical supervision. What better example of this than the traditional Chinese medicine aristolochia?"
Editor 

A black cat, in a dark room, is hard to find. Especially when it is not there…(Kung Fu Tzu)The story of Aristolochia and its toxicity has cast a twenty year long shadow over Traditional Chinese
Herbal Medicine (TCHM) and Complementary and Alternative Medicine alike. Although new cases
have not occurred in the past decade, the same evidence and incidence is being recycled year
after year in scientific papers, invariably referring to these cases to highlight the dangers of (herbal)
quack-medicine. Under the heading ‘Quackery’ and the title ‘Aristolochia: the malignant truth’, The
Lancet deemed it necessary to freshen up our memory once more in its January issue.  For different reasons, all highlighted further on, writing about Aristolochia is an extremely delicate matter, technically as well as ethically. Therefore, let it be clear in advance that nobody in his right
mind disputes the ban on Aristolochia species.

However, the Lancet article is one more sad example of how this case is abused for other agendas: highlighting the dangers of unlicensed medicines, the alleged absence of testing and quality control and the inevitable connection to quackery. It is simply revolting how the authors connect a case of arsenic poisoning and, bloody hell... the death of King George III, to the case of Aristolochia. The saying goes that for a man with only a hammer, everything begins to look like a nail…. It is remarkable that the virulent attacks on traditional herbal medicine are systematically reduced to the problem of Aristolochia, in an unprecedented stream of scientific echolalia, without providing new information or even mentioning the existence of alternative and more nuanced hypotheses.

The Belgian case: not a quack or herbalist to be seen
First of all one should be aware that the Aristolochia stigma on TCHM, goes back to the major ‘clear-cut’ case in Belgium, a drama that took place exclusively in the medical prescription and pharmaceutical dispensing circuit. No quack nor even a herbalist on the horizon! It beggars belief that the sceptic establishment points its guns so disproportionally to herbal medicine at a time juncture when all aspects of safety-efficacy evaluation for regular medicine are under scrutiny.

In Belgium, 2000 deaths per year are officially attributed to licensed medicine (overdosages not
included). A list of over 1600 licensed products considered ineffective is circulating in EU. On a
regular basis phase ‘1-3 clinically tested medicinals’ are withdrawn from the market because of severe side-effects and deaths. Can the authors present a similar negative curriculum for botanical food supplements and medicinals? Moreover, recent research points out that in one third of scientific
papers, results and data are ‘massaged’ under the urge to publish, and more and more cases of
scientific fraud are being revealed. Likewise, the selective combination of truths, half-truths,
concealment and conjecture that characterizes the Aristolochia hypothesis leads one to suspect that
plenty of anomalous information was diligently transformed into accomplished fact. To such an
extent that one would sigh: ‘Where’s Edzard Ernst when you really need him?’…. because this case
cries out for a meta-analysis.

The poverty of the EU model
Meanwhile in the ‘usual suspects’ discourse that we are so familiar with, clearly reference is made to
Aristolochia to legitimize the stringent safety and quality guidance as required under the THMPD.
However, this EU directive involves a registration model that wrings traditional phytotherapy into an
unworkable straitjacket since it fails dramatically to reconcile statutory regulation with efficient
Quality Safety-control. The EU model seems to solve all problems that have never existed, and
leaves the few real problems unsolved. It is symptomatic for the poor understanding of traditional processing by the regulatory authorities, and shows how little lessons have been drawn from
the Aristolochia tragedy: traditional ingredients should not be used frivolously outside their
traditional context and preparation form, which are quite specific.

Aristolochia: vital to distinguish intrinsic toxicity and the wider context of its use
Since all potential safety issues associated with herbal remedies seem to epitomize in the case of
Aristolochia, it may be worthwhile to distinguish the real, intrinsic toxicity from the circumstantially
caused damage. Coming back to the Belgian case, some facts that were poorly highlighted in the
scientific papers.

The Aristolochia case involved an adulteration of species due to poor identity control by the
responsible supervising pharmacists! Aristololochia fang ji (Guang Fang Ji) was used instead of Stephania tetrandra (Han Fang Ji).

Both the original herb and the adulterant are only remotely indicated for the intended diuretic action and both herbs were traditionally prescribed as ingredients of a classical formula or a multi-herbal tailored prescription, not as single ingredient.

The herbs were prescribed by medical doctors devoid of any experience with TCHM. All
recommendations regarding dosage, processing, length of administration and traditional contraindications were systematically ignored.

The herbal ingredients were added to a cocktail, consisting of dexfenfluramines, diethylpropion,
diamox, meprobamate, a.o. All of these licensed medicinals were withdrawn from the market in the years to follow because of severe side effects. Two of those turned out to cause cardiac  alvulopathies and peritoneal and pulmonary fibrosis similar to the pattern encountered in the majority of the victims.

It is commonly accepted that the common denominator in all cases of interstitial fibrosis as
established in the victims, was Aristolochia. This is basically correct, but of little use, since
thousands of women visiting this slimming clinic, were administered Aristolochia but did not
develop such pathology. Far more interesting is the fact that all victims but one, issued from one
surgery where, in a 4 month stretch, high dosages of serotonin enhancers were injected.
Not a single victim issued from the 4 surgeries where the same criminal cocktail was administered for 2 years. The epidemiological data of this unsavoury case were never published in full. The combination of high dosages of administered serotonin with the dexfenfluramine which prevents the re-uptake of serotonin by blocking the 5-HT receptors turned the poor women into ticking time-bombs calling for more tranquillizers (meprobramate) and high amounts of diuretics. Several expert nephrologists pointed to serotonin as the principal causative agent of the rapidly progressing interstitial fibrosis, but their voices went unheard in the subsequent hysterical aristophobia. [1]

It is very well possible that Aristolochic Acid is partly responsible for this fibrotic syndrome, but
only in a secondary phase of the evolving pathology since the kidney lesions rather point to serotonin. Unlike what the papers say, the toxicity of the Aristolochia plant is well known from pharmacopoeae all over the world and comparable to colchicine. Pathology is acute and reversible, unlike the chronic, degenerative and irreversible renal failure syndrome encountered in the victims. In Hippocratic medicine Aristolochia is considered a powerful amphoteric drug (ie a drug with opposite characteristics). In this context amphoteric means that it has the ability to act as an acid and as base. As such it may have played a part in the pathology, given the fact that, while trying to restore the acid/base balance on the level of the extra-cellular matrix (in obese people already tending to grave
acidosis!), it may have contributed to turn the extra-cellular matrix more alkaline, thus further
polarising a pre-existing disbalance and accelerating the fibrotic process.

Again, under such extreme conditions the role of Aristolochia is to be considered secondary, but it was the wrong ingredient at the wrong place and the wrong time. As such, it proved the ideal scapegoat for the scientific community to reduce the incredible complexity of this pathology to Aristolochia uniquely, but also the ideal escape route for irresponsible doctors and negligent pharmacists only driven by  unscrupulous pursuit of profit.

The bottom line is that the epidemiological data hardly implicate Aristolochia in the kidney
pathology. At a very conservative estimate at least 15000 people were exposed to Aristolochia
between 1989 and 1993. Herbalists prescribed tailored combinations with Aristolochia for the
treatment of fistula with amazing results. All in ‘tempore non suspecto’… It is remarkable that
only a relatively small number of people, concentrated in one place, developed the fibrotic syndrome. In 2001 the Belgian Ministry of Health conducted a large-scale inquiry, inviting everyone to whom Aristolochia/Stephania had been administered, for a free kidney screening. Between 5000 and 8000 people reacted. (Yes, there is a traceability system in Belgium.) Not even one new case nor suspicious mortality has been reported.

How about the alleged carcinogenity of Aristolochia? The carcinogenic properties of AA have only been established in rodents and are due to anaerobic bacterial nitroreduction in the forestomach of rats , a mechanism that cannot be extrapolated to humans. If the mechanism would apply, we talk about exorbitant dosages to which no human being has ever been exposed.

The urothelial carcinoma affecting some of the Belgian victims in the slipstream of the renal
pathology, was immediately attributed to AA. Subsequently, AA-DNA adducts were discovered
in their renal biopsies by a research team Heidelberg. [2] The results turned out to be qualitatively and quantitatively impossible but were slavishly swallowed by the scientific community, despite multi-leveled incongruities with previous results. One of the co-operators at the time, Professor A. Pfohl-Leszkowicz, could not reconcile to the outcome of the assay and conducted her own research in which she put forward the hypothesis of ochratoxine as the source of BEN, the Balkan Endemic
Nephropathy, also attributed to Aristolochia. The ochratoxine hypothesis gained momentum when
she was able to re-examine original biopsy samples from the Belgian victims. She identified the adducts as ochratoxine-adducts, and at the same time highlighted the major flaws and anomalies in the AA-hypothesis.[3][4][5]

Despite the absence of sound contra-arguments, her conclusions are mainly hushed up among
toxicologists. The reason? The big food concerns stick to the AA-hypothesis since the costs for QS
control on their cereals would increase exponentially if the OTA-hypothesis were proved right. Interestingly, in the early nineties, a Belgian expert group, advisory to the Department of Health, came to a similar conclusion, but at that time one could not let the truth interfere with a good story…

It is little known that on the basis of the argumentation above and after hearing experts from both sides two Courts of Law final verdicts (Belgium and France) confirmed the absence of any proven causal link between the pathologies and the herbal ingredients!

The Lancet article concludes as follows: "…when comparing conventional therapies with unlicensed
or under-eveluated herbal products, the old Irish anecdote : ‘better the devil you know than the devil
you don’t’, might be more appropriate…"  This quote illustrates the condescending arrogance that , by
combining selective information and model-based biases, finishes off herbal medicine. And, while
talking about the devil you know…What to think about the huge slimming scandal in France where a
big pharmaceuthical company is standing trial for causing the death of at least 500 people and serious valvulopathic complications in over 30000 patients. The licensed medicine Isomeride (Mediator) was registered as an anti-diabetic but promoted and prescribed exclusively as an appetite depressant. Incidentally, Isomeride is a molecule that comes close to the dexfenfluramine discussed above, in fact it is a chemical disguise for it and it shares its destructive properties. As early as 1992 and as a result of the ‘Chinese Herb drama’, the Belgian authorities were alerted about its implication in the valvulopathies and the fibrotic syndrome. However, the inconvenient truth was kept in the dark for years while the Belgian researchers were pasting together the Aristolochia hypothesis, the more convenient scapegoat. Had there been an objective assessment and nuanced communication the French drama could have been avoided and the health of tens of thousands of people would not have been jeopardized. No herbs involved this time. ‘Unlicensed and underevaluated’: did we read correctly ?

Again, this is absolutely not a plea for lifting the ban on Aristolochia. But as long as the truth
remains in exile, and the ‘open ends’ in every hypothesis remain, it would be helpful to stop the
vitriolic attacks on herbal medicine, especially in cases where the tradition is abused by criminals
who disguise molecules like sibutramine, sildenafil and others as herbal remedies. It has been 20
years chewing on the same story and really, there’s no more juice in it.

References
[1] De Broe. On a nephrotoxic and carcinogenic slimming regimen: American Journal of Kidney Diseases. Vol 33 no. 6, 1999, pp 1171-1173.

[2] Bieler C., Stibirova M., Wiessler M., Cosyns J-P, van Ypersele de Strihou C., Schmeisser H. 32P-post labelling analysis of DNA adducts formed by aristolochic acid in tissues from patients with Chinese herbs nephropathy. Carcinogenesis. 1997 May;18(5):1063-7.

[3] Pfohl-Leszkowicz A. Ochratoxin A and Aristolochic Acid Involvement in Neuropathies and Associated Urothelial Tract Tumours. Arh Hig Rada Toksikol 2009;60:465-483.

[4] Mantle PG, Faucet-Marquis V, Manderville RA, Squillaci B, Pfohl-Leszkowicz A. Structures of Covalent Adducts between DNA and Ochratoxin A: A New Factor in Debate about Genotoxicity and Human Risk Chem. Res. Toxicol. 2010, 23, 89–98 89.

[5] Expertise Médicale. Considerations critiques, Note Définitive, Conclusions Générales, par Dr. D. De Keukeleire, Dr. A. De Vriese, Dr. J. Halewyck de Heussch, Dr. N. Lameire et Dr. P. Wettendorff (unpublished).

About the Author: Chris Dhaenens is a herbalist and acupuncturist. He trained at the European
University of TCM, Antwerp, and at the International Acupuncture Training Center, Beijing.
He is president of O.P.P.A.S, a professional association of herbal companies represented in the
Belgian regulatory commission on plants and plant preparations, and also president of the European
Benefyt Foundation, a professional association striving for an appropriate legal framework for
Traditional Herbal Medicine in the EU.

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.

“Anxiety” is a modern term that does not have an exact equivalent in Chinese medicine.
There is no Chinese medicine term that corresponds exactly to what we call “anxiety” but several ancient Chinese disease entities closely resemble anxiety.  The four main disease entities that correspond  to Anxiety are:

“Fear and Palpitations” (Jing Ji)  惊悸 

Fear is the emotion that pertains to the Kidneys and I would like to make three points.  Firstly, “anxiety” does not correspond only to “fear”: it also corresponds to “worry” and “pensiveness” in Chinese medicine.

Secondly, we normally say that fear depletes Kidney-Qi and it makes Qi descend.  The Su Wen in chapter 39 says: “Fear leads to loss of Jing which results in obstruction of the Upper Burner, when this is obstructed Qi cannot return [to it] and this causes distension of the Lower Burner, that is why it is said that Qi sinks.”

This statement from the Su Wen is interesting in that it says that fear blocks the Upper Burner (resulting in Qi of the Lower Burner to descend): this would imply that fear does not simply “make Qi descend” (as we usually say) but that it also causes some Qi stagnation in the Upper Burner.

I personally think that fear actually makes Qi rise and fright makes Qi descend.  The description of Jing Ji by Zhang Jing Yue implies that, in fear, Qi rises: “In Fear and Palpitations [Jing Ji], the Heart, Spleen, Liver and Kidneys are involved.  Yang is connected to Yin and the Heart to the Kidneys. [In this disease] the upper part of the body is restless because it cannot link with the lower part; Heart-Qi is deficient and cannot connect with the Jing [of the Kidneys].”

Dr Zhang’s description of the pathology of Zheng Chong also implies that fear makes Qi rise: “In Panic Throbbing [Zheng Chong] the heart is shaking in the chest, the patient feels fear and anxiety.  There is Yin deficiency and exhaustion; there is Yin deficiency below so that the Zong Qi has no root and Qi cannot return to its origin.  For this reason, there is shaking [or throbbing] of the chest above and also throbbing on the sides of the umbilicus.”

The above statements by Zhang Jing Yue are interesting because they confirm my experience according to which fear makes Qi rise (rather than descend).  In fact, in the statement above, Zhang Jing Yue says that in “Fear and Palpitations”, there is restlessness above and a disconnection between the Heart and Kidneys with Qi rising.

Thirdly, although fear is the emotion pertaining to the Kidneys, other organs also give rise to fear and anxiety and I am presenting below passages from the Su Wen and Ling Shu highlighting connections between fear and organs other than the Kidneys.

Su Wen chapter 39
“Fear leads to loss of Jing which then results in obstruction of the Upper Burner, consequently leading to return [back up] of Qi and distension in the Lower Burner.”

This passage is actually similar to the passages by Zhang Jing Yue quoted above.  It makes the point that fear leads to obstruction of the Upper Burner.  It confirms the relationship between fear and Kidneys as it says that it leads to loss of Jing.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 221.

Su Wen chapter 62
“Surplus of Blood leads to rage while insufficiency of Blood results in fear.”

This passage correlates fear with the Liver saying that Liver-Blood deficiency results in fear.  This is an important correlation as it is a common one in practice, especially in women (in whom Liver-Blood deficiency is common).

The “fear” deriving from Liver-Blood deficiency is related to timidity, lack of initiative, fear of acting, inferiority complex.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 334.


Su Wen chapter 19
“Excessive fear lead to subjugation [of the Kidneys] by Spleen-Qi.”

This is an interesting and unusual view according to which fear leading to a deficiency of the Kidneys may be caused by a pathology of the Spleen (Earth overcoming Water).  This would occur when the Spleen is affected by pensiveness and worry.  This type of fear therefore is close to worry.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 118.

Su Wen chapter 23
“The disorder of Heart-Qi causes belching; the disorder of Lung-Qi causes cough; the disorder of Liver-Qi causes excessive talking; the disorder of Spleen-Qi causes acid reflux; the disorder of Kidney-Qi causes yawning and sneezing; the disorder of Stomach-Qi causes rebellious Qi, hiccup and fear.”

Note by Wang Bing: “When the Stomach is hot, the Qi of the Kidneys is feeble and weak; hence this causes fear. When the Earth harms the Kidneys, the Shen has fear.”

This is an interesting passage that relates fear to rebellious Stomach-Qi. I think this would be particularly Panic Disorder (panic attacks).  The Great Luo of the Stomach (called Xu Li) goes to the heart and it affects it on a physical and mental-emotional level.  On a physical level, it may cause palpitations or tachycardia.  On a mental-emotional level, it may cause a panic sensation with a feeling of energy rising to the chest and head.  ST-40 Fenglong would be the point to use for this.

1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Di Nei Jing Su Wen ), People's Health Publishing House, Beijing, first published ca 100 BC, p. 150.

Ling Shu chapter 8
“The Liver stores Blood and the Blood houses the Hun. Deficiency of Liver-Qi causes fear while excess of Liver-Qi causes anger. Constant fear and pensiveness will damage the Shen and damage of the Shen in turn will lead to fear and seminal emissions.  Excessive fear and fright will scatter the Shen and make it difficult to be contained [to be gathered].  Excessive fear and pensiveness will damage the Shen.  Damage of the Shen in turn will lead to deprivation of the ability to control oneself due to fear.  Constant fear without relief will damage the Jing and damage of the Jing will cause weakness of bones, impotence and habitual seminal emissions.”

The first sentence of this passages relates fear to a deficiency of Liver-Qi (chapter 62 of the Su Wen related it to Liver-Blood deficiency). Liver-Qi deficiency does exist and it usually causes depression: therefore, in this case, the person would be anxious and depressed.

The further sentences of this chapter say that fear damages the Shen and the Jing (and therefore Kidneys).

1981 The Yellow Emperor’s Classic of Internal Medicine- Spiritual Axis (Ling Shu Jing), People's Health Publishing House, Beijing, first published ca 100 BC, p. 23.

END NOTES
1.  Unschuld P Huang Di Nei Jing Su Wen, University of California Press, Berkeley, 2011, p. 401-2.

I have been consulting the Nei Jing for 35 years initially in its French translation (by Chamfrault) and later in Chinese. As we all know, the Nei Jing is a mine of information and most of the things we do in practice are in this text.

It should be stressed that the Nei Jing was written by many different doctors and edited several times notably during the Song dynasty.  For this reason besides containing all the familiar theories, the Nei Jing also has many passages that present unusual theories.  This clinical tip and subsequent ones will discuss the more unusual aspects of the Nei Jing, the first one being about the Heart.

The Heart and the eyes 
There are many passages of the Nei Jing that make correlations between a Zang and the sense organ that are different than the usual ones (e.g. Liver and eyes, Lungs and nose, etc.).  For example, chapter 81 of the Su Wen correlates the Heart to the eyes. It says “Among the 5 Zang, the Heart is the orifice of the eyes and a good lustre of the eyes is a manifestation of the Heart.”

As we know from diagnosis the lustre of the eyes is a very important manifestation of the state of the Shen. Eyes with lustre indicate a good state of the Shen while dull, lustreless eyes indicate long-standing emotional problems.

Apart from the eyes being the orifice of the Heart from a Shen perspective, the Heart also influences the eyes on a physical level.  Chapter 11 of the Ling Shu describes the pathways of the Divergent channels and the Heart Divergent channel goes to the inner corner of the eyes.  A redness in the inner corner of the eyes often indicates Heart-Fire and not necessarily Liver-Fire as we may be inclined to conclude (given the close relationship between Liver and eyes).

Another connection between the Heart and eyes is that the Heart Luo channel goes to the eyes.

To treat eye problems related to the Heart such as redness or blood-shot eyes especially in the inner corner the best point is HE-5 Tongli; if there is Heart Fire I would add HE-8 Shaofu.

The Heart and the nose
Of course the nose is the orifice of the Lungs from a 5-Element perspective, but chapter 11 of the Su Wen makes a correlation between the Heart and the nose. It says “The five flavours enter the nose and are stored in the Heart and Lungs. That is why disorders of the Heart and Lungs can cause nasal obstruction.”
In case of nasal obstruction related to the Heart I would use HE-9 Shaochong.

The Heart as the Root of Life
We generally refer to the Kidneys as the root of life because they store Jing. Chapter 9 of the Su Wen states that the Heart is the Root of Life. In this context the Heart is considered the root of life because it houses the Shen. In fact this chapter says “The Heart is the Root of Life because it houses the Shen.”

This is an interesting statement because it relates the Root of Life both to the Kidneys (because they store Jing) and the Heart because it houses the Shen. This highlights the important connection between Fire and Water and between Heart and Kidneys. In other words our constitution depends not only on the Jing of the Kidneys but also on the Shen of the Heart.

In order to influence the Root of Life of the Heart I would use HE-7 Shenmen and Ren-15 Jiuwei.

The Heart and the ears
Chapter 4 of the Su Wen makes an unusual correlation between the Heart and the ears. It says “The Heart opens into the ears and stores Jing in the Heart.”

Generally, ear problems such as deafness or tinnitus are related to the Kidneys. However such problems maybe related to the Heart especially when there is a deficiency in the Upper Burner with Heart-Qi not rising to the head. We would know this from the pulse being weak in both cun positions. To treat this type of ear problem related to the Heart I would use HE-5 Tongli.

END NOTES

SU WEN CHAPTER 81 and TEARS Chapter 81 of the Su Wen has an interesting view of sadness and tears. The Jing of Water is Zhi and the Jing of Fire is Shen. The interaction of Water and Fire causes sadness of both the Zhi and the Shen and that is why tears run out of the eyes.  An old proverb says: "The sadness of the Heart is in fact the sadness of the Zhi." The Jing of the Zhi and Heart accumulate in the eyes. Thus when both Heart and Kidneys are sad, Shen Qi goes to the Heart, Jing rises and does not go to the Zhi so that the Zhi alone is sad. That is why tears run out.1 Zhang Jie Bin (also called Zhang Jing Yue) commenting on this chapter says: "In case of sadness Shen Qi is transmitted to the Heart. When it is transmitted to the Heart the Jing is not transmitted downwards to the Zhi, the Jing collects above and Zhi is depleted below. As a result the Zhi alone generates sadness and the Jing has nothing to control. Hence the Water is not stored below and the tears appear above."    This passage from the Su Wen highlights several interesting points. The first is the view that both Fire and Water (and therefore Heart and Kidneys) are transformations of Jing. The second is that both Heart and Kidneys influence the eyes (and not just the Liver as we would think according to the 5-Element correspondences). The other very interesting view is that the emotion of sadness is related to Heart and Kidneys and not just the Lungs as we would think according to the 5-Element correspondences. The fourth point highlighted by this chapter is that tears are a fluid derived from the Kidneys. Interestingly, my teacher Dr. Shen used to say that, when a person is very sad but does not cry, fluids do not come out in the form of tears and this may injure the Kidneys.  This may seem strange as, according to 5-Element correspondences, tears are the fluids of the Liver.2 However, this refers first of all to the tears running out when the eyes are exposed to wind, rather than the emotional tears from sadness.  Also, the relationship between the Liver and eyes refers to good vision, again, rather than the emotional tears from sadness.3 Points: Sadness of the Heart and Kidneys: Ren-15 Jiuwei, HE-7 Shenmen, KI-9 Zhubin, Ren-4 Guanyuan. Sadness of the Lungs: LU-7 Lieque, LU-3 Tianfu Three Treasures remedies: For the Heart and Kidneys: Strengthen the Root (for Kidney-Yang deficiency), Nourish the Root (for Kidney-Yin deficiency) with Calm the Shen For the Lungs: Open the Heart or Soothe the Shen  http://www.three-treasures.com/ http://www.acureausa.com/ END NOTES 1. 1979 The Yellow Emperor's Classic of Internal Medicine-Simple Questions (Huang Ti Nei Jing Su Wen). People's Health Publishing House, Beijing, first published c. 100 BC, p. 571. 2. Ibid. p. 22, 31, 70. 3. 1981 Spiritual Axis (Ling Shu Jing灵枢经), People=s Health Publishing House, Beijing. First published c. 100 BC., p. 49.