QIU Chang-lin's Experience in the Differential Treatment of Senile Dementia Based on Phlegm Academic research paper on "Clinical medicine"

QIU Chang-lin's Experience in the Differential Treatment of Senile Dementia Based on Phlegm

LIN Zu-hui

TCM Department of Cardio-Cerebral-Vascular Diseases, Lishui Municipal People's Hospital, Lishui 323000, China

Senile dementia refers to the various dementia syndromes occurring in the geratic period, including Alzheimer's dementia (AD), vascular dementia (VD), and mixed type dementia. It is mainly manifested by disturbance of intelligence and cognition, which falls into the TCM category of 'dementia', 'idiocy', 'amnesia', and 'melancholia'. At present, this disease is considered by TCM differentiation to be excess in superficiality and deficiency in origin, and should be treated for clearing away pathogens and strengthening the body resistance at the same time. Having engaged in TCM clinical practice for more than 40 years, Dr. QIU Chang-lin has treated this disease based on the differentiation of phlegm, and obtained marked clinical therapeutic effects. The author of this article had once the fortune to follow Dr QIU in clinic and learned quite a lot from him. The following is a brief introduction of Dr. QIU's experience in treating senile dementia.

The Etiology and Pathology

Jingyue Quanshu (Jingyue's Complete Works) said: "Dementia patients usually have phlegm, based on which the problem may be gradually induced by mental depression, terror and fear." Dr. QIU holds that senile dementia takes phlegm as its pathogenic basis, while the generation of phlegm is the result of dysfunction of the five-zang organs. For this disease, dysfunction of the five-zang organs happens first, followed by interior formation of turbid phlegm. The spleen (earth) in the middle-jiao should

be the first organ responsible for the interiorly formed phlegm. The spleen is an acquired foundation which transforms and transports the body fluid. Dysfunction of the spleen can lead to failure of transformation and transportation of the body fluid that accumulates to form phlegm. The obstructed phlegm and stagnated qi will further disturb the qi activity in ascending and descending, leading to dysfunction of the liver in promoting free flow of qi and dysfunction of the lung in dispersing and descending, and in prolonged cases, unsmooth flow of the blood, resulting in disorder of the body fluid, qi and blood. The spleen, heart, liver and kidney are all involved in this disease. Moreover, the kidney-qi of old people declines year by year. For those with insufficiency of the kidney-yang, the spleen-yang may fail to be warmed and the transportation of body fluid be disturbed, causing interior formation of turbid phlegm, which goes upward to cloud the mind to cause dementia. For old people with excess of yang or hyperactivity of yang due to deficiency of yin, long-term consumption of yin-fluid by fire can cause formation of phlegm, leading to disturbance of the mind by heat-phlegm, or loss of yin-fluid making unsmooth transportation of nutrients, which fails to nourish the brain and disturbs intelligence, hence the occurrence of dementia. Besides, interior obstruction of turbid phlegm and unsmooth flow of qi and blood in the channels and collaterals can cause interior formation of blood stasis, further leading to accumulation of phlegm and

blood stasis to make the sea of marrow turbid, which may aggravate the state of malnutrition of essential-qi of the brain marrow and disturbance of intelligence, making dementia go severer year by year. In dementia, there can be deficiency within the excess, and excess within the deficiency. The excess syndrome is mostly manifested by 'phlegm, and blood stasis'; while the deficiency syndrome is mostly accompanied with weakness and consumption of the five-zang organs, in which the formation of phlegm remains in the whole course of generation and development of dementia, which is also the main factor for the aggravation of the disease. Therefore, Dr. QIU thinks that 'phlegm' is the fundamental pathological basis of the disease. And he agrees to the idea in Shishi Milu Secret Records in

Stone House) that 'the more excessive of the phlegm-qi, the severer the dementia'.

Experience in the Treatment

1. The combined application of regaining mental clarity by removing phlegm, and soothing the liver and strengthening the spleen: In Bianzheng Lu • Dementia (^fffi^ • M^H Notes on Syndrome Differentiation • Dementia), CHEN Shi-duo said, "Liver-depression will impair the function of the spleen (earth), leading to accumulation of phlegm; while deficiency of the stomach will bring about failure of the spleen (earth) to control water and failure of removal of phlegm but accumulation in the chest surrounding the heart to make the mind unclear, finally developing into dementia." The above explanation suggests that dysfunction of the liver and spleen is closely related with the formation of phlegm. Here, dysfunction of the liver in promoting normal flow of qi and mental depression can, on the one hand, cause disturbance of qi in ascending and descending, leading to stagnation of qi and unsmooth transportation of body fluid, which accumulate to form phlegm; and on the other hand, liver depression

will attack the spleen to make dysfunction of the spleen, which, mixed with injury of the middle-jiao by food intake, will lead to interior formation of turbid phlegm, and in prolonged cases, make the mind confused and cause dementia. Focusing on the pathological basis of turbid phlegm confusing the mind, in the treatment Dr. QIU follows the principle recorded in Shishi Milu •Chidai Secret Records in Stone House • Dementia) that 'there is no special treating principle for dementia but treating phlegm'. At the same time of treating phlegm, he never forgets that spleen (earth) in the middle-jiao is the origin of phlegm formation, and that the best way to eliminate and resolve phlegm is to ensure free flow of qi and normal flow of liver-qi. Therefore, when making prescription, he always pays attention to the combination of regaining mental clarity by removing phlegm, and soothing the liver and strengthening the spleen, so as to obtain mental clearness. In clinic, for symptoms of decreased memory and intelligence, unclear counting, mental confusion, dull complexion, cough with expectoration of phlegm and epigastric fullness, nausea and poor appetite, sticky or thick-turbid tongue coating, and slippery pulse, herbs such as Ban Xia (^H Rhizoma Pinelliae), Chen Pi Pericarpium Citri Reticulatae), Shi Chang Pu (^S^ Rhizoma Acori Tatarinowii), Fu Ling Poria), and Cang Zhu Rhizoma Atractylodis) are commonly used for eliminating phlegm and strengthening the spleen, and promoting clarity of the mind by lowing down the turbid; and herbs such as Hou Pu Cortex Magnoliae Officinalis), Yu Jin ( ^ ^ Radix Curcumae), Wu Yao Radix Linderae), Huo

Xiang (M^ Herba Agastachis), and Zi Su Geng (^ ^^ Caulis Perillae) can be used for soothing the liver and activating the flow of qi, and resolving turbidity with aromatics.

2. The combination of eliminating phlegm and purging the heart-fire, and subduing yang and

calming the mind with heavy setting (drugs): The pathogenic turbid phlegm is marked by thickness and stickiness, which is difficult to be resolved but easy to confuse the clear mind. If the patient has a constitution with excess of yang and hyperactivity of the liver or exuberance of fire due to yin-deficiency, the turbid phlegm will be mixed with fire to go up and disturb the clear mind, resulting in poor intelligence. Dr. QIU holds that long-term retained phlegm being further burned by fire may become all the more difficult to be resolved, making the patient have repeated attacks, being sometimes dull and sometimes mad. Excessive phlegm can cause mental depression and dullness; while exuberant fire can bring about irritability and restlessness, and difficulty in falling asleep day and night. The exuberant fire can be divided into the excess fire and deficiency fire. Excess fire mixed with phlegm can be manifested by red tongue with yellow-sticky coating, and slippery-rapid-forceful pulse; while upward attack of deficiency fire mixed with phlegm will be manifested by red tongue with little fluid, and thready-slippery-rapid pulse. In the treatment, the principle of 'the excess syndrome should be treated by reducing method and deficiency syndrome should be treated by tonifying method.' should be followed. Dr. QIU also abides the principle of 'using corresponding herbs according to the pathogeneses'. Herbs bitter -cold in nature can be used for reducing the excess in purging the heat, and eliminating phlegm to benefit the mind. For patients with excess syndrome, Huang Lian Rhizoma Coptidis), Huang Qin

Radix Scutellariae), Chao Zhi Zi parched

Fructus Gardeniae), combined with Ban Xia (^H Rhizoma Pinelliae), Fu Ling Poria), Zhu Ru

Caulis Bambusae in Taeniam), Shi Chang Pu (^f Rhizoma Acori Tatarinowii), Yuan Zhi Radix Polygalae), Meng Shi (Lapis Micae Aureus ), and Long Chi Dens Draconis) for

eliminating heat and resolving phlegm, and added

with Yu Jin Radix Curcumae), Hou Pu Cortex Magnoliae Officinalis), and Zhi Qiao Fructus Aurantii) for activating the flow of qi and soothing the liver. For patients with deficiency syndrome mixed with phlegm, Sheng Di Huang (^ Radix Rehmanniae), Mu Dan Pi Cortex

Moutan), Zhi Mu Rhizoma Anemarrhenae),

and Bai He (W^ Bulbus Lilii) are often used for nourishing yin and eliminating heat; combined with Ban Xia (^H Rhizoma Pinelliae), Zhu Ru (ffi^ Caulis Bambusae in Taeniam), Ge Gen Radix Puerariae), Gua Lou Pi (^ M & Pericarpium Trichosanthis), Shi Chang Pu (^f Rhizoma Acori Tatarinowii), and Yu Jin Radix Curcumae) for eliminating heat and resolving phlegm; and added with Zi Bei Chi Concha Mauritiae) and Long

Chi (Mffi Dens Draconis) for suppressing yang and calming the mind. For those with excessive heat and constipation, Da Huang Radix et Rhizoma Rhei) can be used for reducing the excess fire; while Huo Ma Ren Fructus Cannabis), and Gua Lou Zi

(i Semen Trichosanthis) can be used for reducing the deficiency fire through resolving phlegm and loosening the bowels.

3. Never forget promoting blood circulation while eliminating phlegm: Stagnated turbid phlegm tends to obstruct the flow of qi, and unsmooth flow of qi may slow down the flow of blood, which further leads to gradual formation of blood stasis, resulting in diseases due to turbid phlegm and blood stasis. The mixture of phlegm and blood stasis obstructing the brain collaterals can make clear yang fail to go upward and the brain loose intelligence, hence the occurrence of dementia. In Dr. QIU's view, the intractable and protracted nature of the disease is mainly because of the sticky turbid phlegm making it difficult to eliminate blood stasis, and the declined function of the five-zang organs in old people, which makes phlegm and blood stasis easy to generate again. Therefore, he stands for adding herbs capable of

promoting blood circulation to the prescription, such as Dan Shen (Radix Salviae Miltiorrhizae), Chuan Xiong Rhizoma Chuanxiong), Mu Dan Pi Cortex Moutan), Dang Gui Radix

Angelicae Sinensis), Yu Jin Radix Curcumae), and Tao Ren Semen Persicae), so as to resolve phlegm, eliminate blood stasis, and activate the flow of qi. When the channels and collaterals in the brain are smooth, the brain marrow is nourished; the senile dementia can be alleviated or controlled.

4. Keeping persistent regulation and treatment in strengthening the spleen for resolving phlegm and tonifying the kidney for benefiting intelligence: Old people tend to have consumption and deficiency of the kidney, and deficiency of the spleen. Those with deficiency of the spleen can have the formation of phlegm due to inability of body fluid to function; and those with deficiency of the kidney can have the formation of phlegm obstructing the collaterals due to qi failure to transform into body fluid. If the kidney-yin is deficient, the deficient fire will burn the body fluid and turn it into phlegm, and the slow stagnated flow of blood fails to nourish the brain by blood and body fluid. When spleen and kidney yang are deficient with dysfunction of warming, then yang can not be transformed into yin, leading to interior accumulation of deficient cold , stagnation of body fluid, interior formation of cold phlegm, spasm of channels and collaterals, unsmooth blood flow, and malnutrition of the clear mind, resulting in occurrence of dementia. Dr. QIU holds that the restoration and normal function of the spleen and kidney would play a very important role in treating this disease and consolidating the therapeutic effects. Therefore, the treatment at the mid and late stages and the treatment for consolidating therapeutic effects are often based on the functioning condition of these two organs. Usually, strengthening the spleen goes first, for only when the spleen is strengthened and the phlegm is resolved, can the tonification and

nourishment really work. Or, tonifying both the spleen and kidney can start after the phlegm is resolved. When the kidney is being tonified, attention should be paid to preventing overuse of heavy tonics. Or herbs for enlivening the spleen can be used in combination with these heavy tonics. Of course, soothing the flow of qi can not be ignored in the meantime of tonification. In Dr. QIU's view, strengthening the spleen does not simply mean reinforcing qi, the purpose is more focused on resolving phlegm in the strengthening of the spleen in transportation. Therefore, herbs such as Huang Qi (^ "K Radix Astragali),Tai Zi Shen (Radix Pseudostellariae), Shan Yao ( Lb ^ Rhizoma Dioscoreae, and Chao Bai Zhu (^ S ^ parched Rhizoma Atractylodis Macrocephalae) are often used in the prescription for strengthening the spleen in transportation and resolving phlegm. Tonifying the kidney is not only for replenishing essence, but more for promoting intelligence and benefiting the brain. Herbs capable of nourishing the kidney and essence, promoting intelligence and benefiting the mind are often added in the prescription, such as Huang Qi (^ K Radix Astragali), Tai Zi Shen ((Radix Pseudostellariae), Shu Di Huang (Radix Rehmanniae Preparata), Gou Qi Zi (ff^ET Fructus Lycii), He Shou Wu (M ^ ^ Radix Polygoni Multiflori), and Yin Yang Huo (S^M Herba Epimedii).

Sample Cases

Case 1: A female patient, aged 84 years, paid her first visit on August 21, 2001, with the chief complaint of progressive decrease of memory, accompanied with decreased daily life ability for 7 years. The problem was getting worse. She was once diagnosed to as having 'senile dementia'. In recent half a year, the symptoms were obviously getting worse, and she was unable to do housework. The patient was accompanied with such symptoms as being doubtful,

anxiety, irritability, restlessness, incoherent speech, difficulty in falling asleep, inability to distinguish relatives from common people, frequent constipation, red tongue with yellow-sticky coating, and wiry-rapid-slippery pulse. The MRI examination of skull suggested encephalatrophy. The score of the Mini Mental State Examination (MMSE) was 12 points. The clinical diagnosis was AD. The TCM diagnosis was 'dementia' due to turbid phlegm obstructing the clear mind, and exuberant fire in the heart and liver. The treating principle was eliminating phlegm to regain mental clarity, purging the pathogenic fire from the liver, and tranquilizing the mind. The prescription: Huang Lian (M^ Rhizoma Coptidis) 6g, Mu Dan Pi Cortex Moutan) 10g, Zhu Ru

Caulis Bambusae Taeniam) 10g, Ban Xia (^H Rhizoma Pinelliae) 10g, Fu Ling Poria) 10g, Zhi Qiao Fructus Aurantii) 10g, Chao Zhi Zi C^MT parched Fructus Gardeniae) 10g, Yu Jin (^ ^ Radix Curcumae) 15g, Shi Chang Pu Rhizoma Acori Tatarinowii) 15g, Dan Shen Radix Salviae Miltiorrhizae) 15g, Long Chi (M'm Dens Draconis) 30g, Zi Bei Chi Concha

Mauritiae) 30g, and Ge Gen Radix Puerariae) 30g, which were mixed and made into decoction. The decoction was taken one dose daily for 14 successive days. On her second visit, the symptoms of irritability and restlessness were alleviated, but her mind was still not clear, and her speech less. The tongue was red with thin-sticky coating, and the pulse was still slippery-rapid. Then Ban Xia (^ H Rhizoma Pinelliae), Fu Ling Poria), and Zhu Ru (ffi^ Caulis Bambusae Taeniam) were left out from the prescription, and Suan Zao Ren (^^^ Semen Ziziphi Spinosae) 30g and Jue Ming Zi (^B^T Semen Cassiae) 30g added. On her third visit, half of the symptoms disappeared, yet she still had constipation, red tongue with thin coating, and wiry

pulse. This time, 14 doses of the prescription were prescribed for the patient, with Zhi Qiao (^^ Fructus Aurantii) left out, and Sheng Di Huang M Radix Rehmanniae) 15g, Bai He (W^ Bulbus Lilii) 15g, Gua Lou Pi (AM & Pericarpium Trichosanthis) 15g, and Gua Lou Zi (AMT Semen Trichosanthis) 15g added. The patient kept on the TCM herbal treatment for more than 2 years, during which the prescriptions were modified according to the symptoms and signs. For restlessness and irritability, Chao Zhi Zi parched Fructus

Gardeniae) and Dan Dou Chi Semen Sojae

Preparatum) were added for clearing heat; for dizziness and blurred vision, and red tongue with little fluid, Bai Shao (S^ Radix Paeoniae Alba), Gou Qi Zi (ff^ET Fructus Lycii), and Nu Zhen Zi (^MT Fructus Ligustri Lucidi) were added to nourish the liver-yin; and for restless night sleep, Bai Zi Ren (ttTfc Semen Platycladi) and Bai He (W^ Bulbus Lilii) were added to sooth the heart and calm the mind. When the mood is calm, and the tongue is red with thin coating, and the pulse thready-rapid, the modified combination of Dihuang Yinzi Rehmannia Decoction) and Liu Junzi Tang (AST ^ Decoction of Six Ingredients) were used for strengthening the spleen and replenishing essence. 3 years later, the patient's condition was stable. She could control her bowel movement and urination, and recognize her relatives. The score of MMSE remained still at 12 points.

Case 2: A female patient, 58 years old, paid her first visit on January 10, 2003. The patient said that in recent half a year she was becoming indifferent, accompanied with slow response, dizziness and tinnitus, poor appetite, dislike of exercise, forget-fulness of recent events, numbness of the left limbs, inability to count to 10, less doing of housework, and constipation. She presented a slightly-red tongue with

sticky coating, and slow-slippery pulse. The MRI examination of the skull suggested several foci of lacunar infarction and ischemic malacia in the basal ganglia. The Doppler ultrasonic examination suggested insufficient blood supply of arteria cerebri media, and poor arterial elasticity. It was differentiated by TCM as 'dementia' due to turbid phlegm obstructing the clear mind and making dysfunction of mental activity. The treating principle was eliminating phlegm to regain mental clarity, and relieving depression to promote resuscitation. The prescription: Ban Xia (^H Rhizoma Pinelliae) 10g, Cang Zhu Rhizoma Atractylodis) 10g, Chuan Xiong Rhizoma Chuanxiong) 10g, Yu Jin (^ ^ Radix Curcumae) 10g, Chen Pi Pericarpium Citri Reticulatae) 6g, Yuan Zhi (® ^ Radix Polygalae) 6g, Bai Hua She She Cao (S^^^^ Herba Hedyotis Diffusae) 6g, Huang Jing ( Rhizoma Polygonati) 15g, Dan Shen Radix

Salviae Miltiorrhizae) 15g, Shi Chang Pu (^S' Rhizoma Acori Tatarinowii) 20g, Jue Ming Zi (^ HQ T Semen Cassiae) 30g, and Huo Ma Ren (^0-f^

Fructus Cannabis) 30g, which were mixed and made into decoction. 14 doses were prescribed and taken one dose daily. On her second visit, the patient stated that her dizziness and tinnitus were alleviated, and memory was obviously better. The tongue was light-red in proper with thin-sticky coating, and the pulse still slow. She continued taking 14 doses of the original prescription, with Cang Zhu Rhizoma Atractylodis) left out, and Yi Zhi Ren (ffi^-f^ Fructus Alpiniae Oxyphyllae) 15g and Fu Ling Poria) 15g added. On her third visit, the patient said that her bowel movement was smooth, dizziness relieved, food intake increased, and numbness of the left limbs alleviated, and she could correctly count from one to a hundred. Then she kept on administration of the original prescription for consolidation, with Huo Ma Ren (^0-f^ Fructus Cannabis) left out, and Bai Ji Li (S^^ Fructus Tribuli) 12g, Gou Qi Zi (fET Fructus Lycii) 15g, and Yi Zhi Ren (ffi^-f^ Fructus Alpiniae Oxyphyllae) 15g added.

(Translated by WANG Xin-zhong