This is the fourth and final of a group of newsletters which deal with the four ages of humankind. The first was dedicated to children, the second to adolescents, the third to adult age and this final one will focus on old age, i.e. above 65 years old.

The Treatment of Diseases of Old Age

Geriatrics has been a separate speciality in China since the beginning of Chinese medicine, whereas in the West it has only formed a separate speciality since the 1940's. The prevention and treatment of disease in old people has acquired more and more importance due to the rising proportion of old people compared to the rest of the population. The percentage of the population over the age of 60 in 1911 was 6.8 whereas by 1981 it had risen to 17.7. This is a trend in all industrial Western societies so that caring for the elderly is a very important social problem.

The Chinese attitude towards old age
The attitude to old age and the elderly varies considerably between the West and China. Since Confucian times, respect for the elderly has been ingrained in the Chinese whereas in Western societies the elderly are often seen as a burden upon society and have no clearly defined role. Whereas in the West there is a tendency to try and stop the aging process with the use of plastic surgery and drugs, the Chinese have traditionally looked forward to old age and work with the natural physiological processes that take place at this time in life to make the aging process as smooth as possible.

Many of the most eminent Chinese doctors in history lived very long lives. The famous Tang dynasty doctor, Sun Si Miao, lived to the ripe old age of 101. Wang Shi Xiong, who lived during the Qing dynasty, died at the age of 110. This is perhaps a testament, firstly, to the preventative benefits of Chinese medicine and, secondly, to its benefits for the elderly.

Chinese Medicine view of geriatric diseases
The traditionally-held view is that the majority of the illnesses most commonly seen in the elderly have a Kidney deficiency at their root. This was expressed in many different ways by Ye Tian Shi. For example, the "Lower Yuan declines", "the Lower Burner root is deficient", "the 6 true Yin decline" or "Water declines". Li Zhong Xin, of the Ming dynasty, stressed that new diseases are Shi while old diseases are Xu. He therefore concluded that for old people it is essential to warm and nourish the Spleen and Kidneys.

A famous quote from Chapter 54 of the "Spiritual Axis" sums up this widely held view that illnesses of old age are predominantly Empty in nature. "At 50, Liver-Qi starts to decrease, the Liver-Blood gets thinner, the Gall-Bladder bile decreases, the eyes cannot see clearly. At 60, Heart-Qi begins to decline, there is sadness, Qi and Blood decrease and one likes to lie down. At 70, Spleen-Qi is deficient and the skin withers. At 80, Lung-Qi decreases, the Po declines and speech is difficult. At 90, Kidney-Qi is burnt out and the energy of the [other] four Yin organs is depleted. At 100, the 5 Yin organs are deficient, the Shen is going, only the body is hanging on and it is near the end."

A different perspective
Contrary to the prevailing view that old people's diseases are dominated by Deficiency, it is my belief and experience that, although most old people do suffer from some deficiency, most modern diseases of old age are actually caused by Full rather than Empty conditions. In my practice, of 372 patients over the age of 65, 219 (59%) of them have purely Full pulses compared to 103 (28%) who have Empty pulses and 50 (13%) who have mixed pulses. The most common qualities of these patients pulses are Full, Wiry and Slippery. 232 (62%) have predominantly Full patterns, which may be Blood stasis, Phlegm, Wind, Dampness, Qi stagnation, Heat, Fire or Liver-Yang rising. It is certainly true that, with age, there is a physiological decline of Kidney energy but this is not, in my experience, what causes many of the most serious diseases of old age. It is important when treating the elderly not to assume that, because the patient may look frail and weak, there are only Empty patterns present and that therefore the treatment principle should be to tonify and nourish. Elderly patients should be diagnosed in the same way as everyone else, i.e paying attention to the pulse, tongue, and signs and symptoms.

The most common Chinese patterns of a Full nature seen in the elderly are the following:

•	Blood stasis
•	Phlegm
•	Internal Wind

The interaction between Phlegm and Blood stasis is typical of many of the most serious diseases of old age. Of course, many young people may have the pathogenic factors of Phlegm and Blood stasis, but in the diseases listed below, they have become causes of disease in themselves. In these cases, Phlegm and Blood stasis are the end result of a long-standing pathological process and hence are only very rarely seen in patients other than the elderly.

The following table illustrates the Chinese patterns frequently present in common diseases of the elderly.

PHLEGM BLOOD STASIS INTERNAL WIND Myocardial infarction T T Angina T T Arteriosclerosis T T Thrombosis T Atheroma T Hypertension T T T Stroke T T T High cholesterol T Chronic bronchitis T Cancer T T Diabetes T T Chronic nephritis T Prostatic hypertrophy T T Parkinson's T Senile dementia T T Trigeminal neuralgia T Dizziness T T

Character for "Longevity" (Shou)

In the past few years, it has become more and more recognized that Full patterns play a role in many of the diseases of the elderly.

Blood Stasis

Signs and symptoms of Blood stasis

General: swellings, lumps, tumours, masses, purple lips, skin and nails, purple nose bridge, dry nails and hair, dry mouth, dark, scaly, dry and lustreless skin which is not elastic, dark maculae, dark moles, dark eye sockets, umbilicus bulging out, fever, aches and pains, bleeding, distension and fullness, hardness on the abdomen on palpation, itching, numbness, stiffness, excessive dreaming, poor memory, withered, dry and yellowish coloured hair, enlarged ends of finger and toes, adhesions and scars from surgery, Wiry pulse, Purple tongue.

Heart: palpitations, stabbing pain, feeling of oppression of the chest, depression, mania, confusion, anxiety, mental restlessness.
Liver and Gall-Bladder: depression, frustration, easily angered, hypochondrial pain, jaundice.
Stomach, Spleen and Intestines: epigastric and abdominal aches, pain, burning pain, distension and fullness, constipation, blood in the stools.
Lungs: shortness of breath, asthma, pain, feeling of oppression or tightness of the chest, dry throat, blood-tinged sputum, dyspnoea.
Kidneys: lower abdominal distension, fullness and pain, turbid urine, painful urination, interrupted urination, scanty urination.

Of the above symptoms and signs, the following, when they are due to Blood stasis, are only seen in the elderly: dry nails and hair, maculae, poor memory, withered, dry and yellowish-coloured hair, enlarged ends of fingers and toes. It is interesting to note that dryness may be caused by Blood stasis and is not always due to Blood deficiency. This is because Blood and body fluids have a mutual interaction and when Blood stagnates, it prevents body fluids from circulating properly so they fail to moisturize the skin and hair.

Three Treasures remedies that address Blood stasis in common diseases of old age: Peaceful Sunset, Red Stirring, Clear the Root.

Pharmacological actions of the Blood-invigorating herbs
It is a common misconception that "moving-Blood herbs" literally move the blood in the blood vessels with the possible danger of moving any clot that might be there. Blood-invigorating herbs do not simply move but actually modify the quality of the blood and, for this reason, I prefer the term "invigorate" rather than "move" Blood.

In China today, the method of invigorating Blood is being used to treat diseases, often seen in the elderly, which were not previously recognized as involving Blood stasis, e.g. chronic nephritis and diabetes.

Blood-invigorating herbs have a very complex action on the Blood and, from a Western perspective, these actions can be summarized as follows:

•	They improve the dynamics of blood flow and dilate the peripheral, coronary, cerebral, renal and mesenteric arteries.
•	They improve microcirculation. Disturbance of microcirculation causes many diseases such as coronary heart disease, angiitis, endometriosis, chronic hepatitis, hepatic cirrhosis and scleroderma.
•	They improve concentration, coagulation and accumulation of blood and prevent thrombosis by inhibiting accumulation of platelets.
•	They influence connective tissues and can treat diseases of these tissues such as skin warts, burn scars and adhesions.
•	They readjust cellular and humoral immunity.
•	They have an analgesic effect.
•	They increase uterine contractions.
•	They combat inflammation and bacterial infection.

Signs and symptoms of Phlegm

General: poor memory, greasy skin and hair, lumps, numbness, dizziness, dark shen of the eyes, dark eye sockets, corners of the eyes have very slight cracks with exudate, sallow complexion, swollen body, puffy face, obesity, sweaty external genitalia, axillae or palms and soles, enlarged fingers and toes, thick thumbs, flaccid skin and muscles, excessive salivation or dribbling, lethargy, Swollen tongue, Slippery or Wiry pulse.

Heart: mental confusion, feeling of oppression of the chest.
Gall-Bladder: gall-bladder stones, nausea, jaundice, inability to digest fats.
Joints: bone deformities, pain, rigidity, stiffness, lack of movement.
Lungs: coughing up sputum, feeling of oppression of the chest, asthma, shortness of breath.
Stomach: poor appetite, bloating, epigastric or abdominal discomfort, mental confusion.

Of the above symptoms, when they are due to Phlegm, the following are only seen in the elderly: enlarged fingers and toes, thick thumbs, flaccid skin and muscles.

Three Treasures remedies that address Phlegm in common diseases of old age: Peaceful Sunset, Clear Yang, Limpid Sea.


INTERACTION BETWEEN BLOOD STASIS AND PHLEGM

Blood stasis and Phlegm have a common origin and there is often an interrelationship between them, especially in chronic conditions. When Blood stagnates over many years, the stagnant Blood obstructs the proper movement of Qi and functioning of the internal organs and impairs the transformation of body fluids, leading to the formation of Phlegm. On the other hand, long-term retention of Phlegm may also cause stasis of Blood simply because the obstructing Phlegm impairs the circulation of Blood in the channels and blood vessels. This situation is so common that some doctors say that one may nearly always treat old people suffering from a chronic, complicated illness for stasis of Blood and Phlegm. Tang Zong Hai, in the "Discussion about Formulae to invigorate Blood and Eliminate Stasis", in fact says: "When Blood stagnates for a long time, it gives rise to Phlegm." It is also said that "Phlegm mixed with Blood stagnation turns to abscesses", a further acknowledgement of the fact that Blood stasis and Phlegm together cause serious diseases.

There are many herbal formulae which illustrate this principle, e.g. Ou Jing Tang Lotus Stem Decoction which is for Lung-Heat and Phlegm with stasis of Blood: it contains Dong Gua Ren Semen Benincasae hispidae and Yi Yi Ren Semen Coicis lachryma jobi to resolve Phlegm.

Many of the most serious diseases seen in the elderly involve both Blood stasis and Phlegm. They are:

•	coronary heart disease (including myocardial infarction, arteriosclerosis, angina etc.)
•	hypertension
•	cancer
•	high cholesterol

INTERNAL WIND

Signs and symptoms of internal Wind

•	Stiffness and rigidity
•	Trigeminal neuralgia
•	Tremor
•	Giddiness
•	Dizziness
•	Vertigo
•	Convulsions
•	Paralysis
•	Stiff or deviated tongue

Three Treasures remedies that extinguish Wind in diseases commonly seen in old age: Peaceful Sunset, Clear Yang, Nourish the Root and Clear Wind.


THREE TREASURES REMEDIES FOR OLD AGE

1. PEACEFUL SUNSET
Peaceful Sunset addresses many of the symptoms most commonly seen in old age, i.e. insomnia, dizziness, tinnitus, trigeminal neuralgia, headaches, coughing up phlegm, constipation, thirst, chest pains, purpura and high blood pressure. It is specific for elderly people with symptoms of Liver-Fire, Blood-Heat, Blood stasis, internal Wind and Phlegm. Also, in old people, Phlegm-Fire is often associated with Liver-Fire and Liver-Wind, with the rising Fire and Wind carrying Phlegm with them. The tongue and pulse pictures of this condition are a reddish-purple and swollen tongue with a dry-sticky yellow coating, and a Full-Slippery-Wiry pulse. The clinical manifestations addressed by this remedy may indicate the possibility of impending Wind-Stroke.

2. CLEAR YANG
Clear Yang was formulated to treat a very common presentation seen in middle-aged and old people, i.e. Liver-Yang rising and Phlegm clouding the head. In elderly people, these two patterns frequently cause chronic and severe giddiness. Phlegm, formed as a result of Spleen deficiency over a long time, clouds the head's orifices and prevents the clear Yang from rising to the head. The clouding of the upper orifices by Phlegm may also cause headaches, dizziness and blurred vision. This formula also extinguishes Wind and, with the appropriate presentation, is therefore also suitable to treat hypertension in old people.

3. DRAIN FIRE
Drain Fire treats Liver-Fire, Heart-Fire, and Damp-Heat in the Upper and Lower Burners, all patterns commonly seen in old age. It therefore has a wide-ranging clinical application treating symptoms in the upper part of the body such as headaches, bitter taste, dizziness and thirst and in the Lower Burner such as cystitis, urethritis and vaginitis. This formula must only be used when there are clear manifestations of Fire, as opposed to Heat. The essential symptoms of Fire are a Red tongue with a dry-yellow coating, a Wiry-Rapid and relatively Deep pulse, a bitter taste, thirst and dry stools.

4. RED STIRRING
Red Stirring is a variation of the ancient prescription "Blood-Mansion Eliminating Stasis Decoction". It is specifically aimed at addressing the patterns of Blood stasis in the chest and mind. It moves Blood, eliminates stasis, moves Qi, stops pain, calms the mind and opens the mind's orifices. The indications for this formula are often seen in elderly patients and include chest pain, a feeling of oppression and heat in the chest, palpitations, mental confusion and depression. From a Western medical perspective, this remedy would be used to treat angina pectoris.

5. CLEAR THE ROOT
Clear the Root is aimed at treating chronic prostate problems such as prostatitis or prostatic hypertrophy. These conditions occur frequently in old people and are most commonly caused by Damp-Heat, Blood stasis and Fire-Poison in the Lower Burner against a background of Qi and Yin deficiency. It may also be used to treat many bladder problems which frequently occur in the elderly in both sexes. The formula achieves its effect by draining Damp-Heat, moving Blood, separate the clear from the turbid, softening hardness, resolving Fire-Poison. It also tonifies Qi and nourishes Kidney-Yin.

6. NOURISH THE ROOT AND CLEAR WIND
Nourish the Root and Clear Wind addresses the common clinical situation of chronic Wind-Damp Painful Obstruction (Bi) syndrome and is especially suitable for chronic rheumatic problems in the elderly. As well as treating the Manifestation (Biao) it also treats the Root (Ben) which, in the case of this formula, is Kidney- and Liver-Yin deficiency.

7. LIMPID SEA
Limpid Sea is a variation of Er Chen Tang Two Old Decoction which is the classical formula to dry Dampness and resolve Phlegm. It does this in many different locations throughout the body and is therefore indicated in cough with abundant sputum, catarrh in the chest, nose or throat, nausea and vomiting, palpitations, dizziness, insomnia and lipomas. It may be used to resolve Damp-Phlegm, Hot-Phlegm or Cold-Phlegm in all diseases of the elderly caused by Phlegm.

8. STRENGTHEN THE ROOT
Strengthen the Root is a variation of the "Restoring the Right [Kidney] Pill" prescription to tonify Kidney-Yang, stoke up the Fire of the Gate of Vitality and fill the Essence. Kidney-Yang naturally declines with age and this may cause symptoms in the elderly such as chilliness, cold feet and limbs, lower backache, weak knees, weakness, tiredness and incontinence of urine.

9. NOURISH THE ROOT
Nourish the Root is a variation of the "Restoring the Left [Kidney] Pill" prescription to nourish Kidney-Yin and Essence. It is suitable for an extremely wide range of problems provided the underlying pattern is Kidney-Yin deficiency. The symptoms indicated are those often seen in old age such as dizziness, tinnitus, sore back and legs, dry mouth and throat, exhaustion, depression, lower backache, dry stools and dry skin and hair.


Case history 1

An 85-year-old man complained of chronic tiredness and dry mouth. He had arthritis of the left hip and had had two operations to replace the joint but these had been unsuccessful because there was bone growing around the prosthesis. This caused him a great deal of pain. He also suffered from hypertension for which he was taking beta-blockers. He also complained of experiencing "flashing lights" in his eyes occasionally.

His pulse was very Wiry all over and his tongue was Reddish-Purple, Swollen with a Heart crack and a yellow coating.

This case is a good example of the fact that old people's chief symptoms and diseases are caused by Full rather than Empty conditions. Although this man has relatively few symptoms, we can diagnose that he suffers from Phlegm, Blood stasis and Wind.

The symptoms of Phlegm are: Swollen tongue and growth of bone around the prosthesis. The symptom of Blood stasis is the Reddish-Purple tongue and the symptoms of Wind are the Wiry pulse, the hypertension and the flashing lights.

I prescribed Peaceful Sunset which addresses the three patterns of Phlegm, Blood stasis and Wind in the elderly. Although this remedy could not help the hip pain, it helped him to feel a lot more energy. This case history is also a good illustration of the fact that tiredness can derive as much from a Full as from an Empty condition.

Case history 2

A 65-year-old man had been suffering from prostate cancer which had spread to the bones. His urination was frequent and rather urgent and the urine was yellow, cloudy and slightly smelly. He also suffered from backache, tinnitus, night-sweating, a feeling of heat and a dry mouth. His tongue was Red and had a sticky-yellow coating. His PSA was 100.

His conditions clearly shows a situation of Damp-Heat in the Lower Burner (sticky-yellow tongue coating, yellow-cloudy-smelly urine) occurring against a background of Kidney-Yin deficiency.

I prescribed Clear the Root which seemed ideally suited to his condition because besides resolving Damp-Heat from the Lower Burner, it also invigorates Blood. Although he did not have any specific symptoms of Blood stasis, in carcinoma of the prostate there is always some Blood stasis which leads to the formation of masses.

His PSA came down dramatically from 100 to 49 in 2 months. After another 7 months his PSA was down to 7.

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