TCM Treatment for Cognitive Decline Patterns

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A Clinical Approach to Treating Complex Cognitive Decline Patterns with Customized Chinese Herbal Medicine

The Huangdi Neijing Suwen, our foundational Chinese Medicine text, teaches that in the human body, the Kidneys are the foundation of vital essence, known as Jing. Jing provides the basis for all growth and development, serves as the root of life, and is the source of our individual constitutional strength. It is through Jing that the brain's functions are supported and nourished. A robust foundation of Jing allows for mental clarity, strong memory, and cognitive function. Constitutionally deficient Jing may be inherited from the parents, or Jing might be gradually depleted over time due to chronic stress, lifestyle habits, and an unbalanced diet. As we age, our Kidney Essence naturally declines, and so our brains go through inevitable changes that are proportional to our reserve of available Jing.

The National Institutes of Health (NIH) report that the most common brain disorders in elderly individuals include Alzheimer’s disease, vascular dementia, mild cognitive impairment, cerebrovascular diseases (including strokes), Lewy body dementia, and Parkinson’s disease. Of course, as Chinese Medicine practitioners we are not treating these conditions directly, but we will see patients with these diagnoses that are seeking our help for symptom relief. As Chinese Medicine practitioners, it can feel daunting when patients with complex Western diagnoses like these show up in the clinic, often accompanied by their families and loved ones. If we can set aside the Western concepts of disease, examine the symptoms and break the patient’s presentation down into logical parts from a Chinese Medicine perspective, then we can create customized herbal treatments to reduce the severity of their symptoms and help improve their quality of life.

In this way, we can experience the power that customized herbal medicine has on positive treatment outcomes. As a Chinese Medicine practitioner specializing in herbal treatment, I would like to share my approach to creating a clinically effective herbal treatment plan for the imbalances associated with the aging brain. My approach is rooted in Classical Chinese Medicine, based on the clinical experience of my teachers, and has evolved for me over the last 15 years in my own Chinese herbal practice.

The Importance of Medical History

For patients with neurodegenerative diagnoses, comorbidities, complex histories, and medications are common. To make sense of their complexities, we should aim to understand their medical journey: What was their health like before the onset of these symptoms, when and how did the symptoms begin, and how have they progressed? Learning about symptom expression before treatment with medication helps us to more clearly identify Chinese Medicine patterns and can help us to understand what role herbal medicine can and should play in their integrative treatment plan. I always ask a patient to [somewhat briefly] tell me their medical story. They often share obscure symptoms or experiences that have been overlooked or minimized by Western doctors, but which offer us important clues. Understanding their frustrations and emotions around their condition and treatment gives us helpful information about the type of pattern we are looking at and the organ systems most affected. For us, an effective herbal formula starts with correct pattern identification and treatment priority.

The Kidney/Brain Connection

From a Western perspective, the brain is the center of consciousness and controls all voluntary and involuntary movements as well as bodily functions. The central nervous system (CNS), made up of the brain and spinal cord, is primarily responsible for maintaining homeostasis and responding to sensory information through the network of the peripheral nervous system. In Chinese Medicine, however, the Kidneys control the brain and central nervous system. This may sound far-fetched until one considers that the brain is made up of at least 75% saline water, and that all of the electrical impulses of the nervous system occur as a result of the movement of this electrolytic fluid. With this in mind, we can see why Chinese Medicine calls the brain and spinal cord the "Sea of Marrow." The Sea of Marrow is where Jing is stored and circulated, under the control and regulation of the Kidneys. In this way, we view the Kidneys as providing the Qi and nourishment needed to support brain function, cognitive abilities, and memory. From this perspective, it is easy to see why our ultimate treatment goal for patients with cognitive impairment is to support healthy Kidney function.

But First, Digestion

First and foremost, in relieving the symptoms associated with disorders of the brain, we need to see that the brain is well-resourced. This means ensuring that it is supplied with enough Qi, nutrient-rich blood, and body fluid to function healthfully. We also want to make sure that these resources are able to move freely through the organ.

In order to get these vital substances to the brain using Chinese Herbal Medicine we access the brain via the Kidney organ system, but in order for herbal medicine to treat the Kidneys, it has to be properly digested and assimilated. There is increasing evidence to suggest that digestive imbalances are associated with neurodegenerative diseases. Western medicine views this as a result of neuroinflammatory processes across the microbiota-gut-brain axis (Cammann et al., 2023). From our perspective though, we can understand this as poor nutrient transformation and absorption, leading to deficiencies of vital substances which leaves the body and brain under-resourced. We have to ensure that digestion is balanced and robust so that the herbs and nutrition can be utilized by the body. Properly identifying and treating the digestive imbalance is the first step in supporting the patient’s brain health. There are too many possible digestive patterns to list within the context of this article, but here are some common ones to keep an eye out for and treatment possibilities to consider.

Poor Nutrition

We want to ask if the brain is receiving enough nutrition. Ultimately, the nutrition we take in becomes our Blood and Qi, so making sure our patients are taking in the necessary building blocks and then transforming them into Blood and Qi is vital to treatment. If not, where is the issue coming from? It may simply be that the patient is in survival mode, eating whatever they can, and not getting enough nutrients in their diet. Working with these patients to create a simple food therapy plan based on the patterns of imbalance you have identified is the best place to start.

Low Appetite and Nausea

Often, we will also see in an elderly or chronically ill population that low appetite makes eating enough food a daily challenge. We want to investigate where this challenge is coming from. Are they nauseated? Has their sense of taste or smell become dulled? Are they not hungry? We can help them to increase their appetite by strengthening the Spleen and Stomach function, and if nauseated, by descending rebellious Stomach Qi.

For simple nausea and reduced appetite, consider using only Ren Shen Ban Xia Gan Jiang Tang. This formula helps to warm and dry Dampness in the Spleen and Stomach to reduce nausea/vomiting and encourage appetite. If there is a more complex digestive pattern involved with inappetence and nausea, then you can select the appropriate formula to treat that pattern and add Gan Jiang Ren Shen Ban Xia Tang. For reduced appetite and Qi deficiency, you may also consider adding Ren Shen, Dang Shen, Sheng Jiang, Da Zao, or Yi Tang to the appropriate base formula.

Other Digestive Problems

If the patient is eating well, but failing to transform their food into usable nutrients due to some digestive impairment, here are some suggestions for identifying and treating common digestive problems:

• For rebellious Stomach Qi caused by glomus (damp/Qi blockage) below the Heart, with nausea, heat symptoms above the diaphragm, loose or alternating loose stool and constipation with pressure around Ren 15, consider Sheng Jiang Xie Xin Tang.
• For rebellious Qi with belching, gas, and reflux with nausea consider using Xuan Fu Dai Zhe Tang.
• For Blood and Spleen Qi deficiency with abdominal tension or discomfort, possible nausea, and reduced appetite, consider Xiao Jian Zhong Tang. For more pronounced Blood deficiency, think about Dang Gui Jian Zhong Tang.
• For Spleen constraint dryness with rabbit pebble constipation, bloating and frequent urination we need to move the bowels and revive the Spleen using Ma Zi Ren Tang.
• For counterflow water with thirst, nausea, inhibited urination and loose stool consider Wu Ling San.

Once we have sorted out the digestion by using gentle herbal medicine and food therapy, we can then move on to more specific treatments for the cognitive symptoms. Even if digestion is not a direct cause of the patient’s cognitive symptoms, it is connected and foundational to supporting their brain health. If your patient can’t digest their herbal medicine, it cannot help them.

Identifying the pattern(s)

We can assume, due to the nature of neurodegenerative disorders, that some or all of the resources (vital substances) to the brain are lacking, so we need to then determine what and why. We want to identify and reverse engineer the deficiencies to treat them at the root. To me, Blood is a good starting point for this process.

Blood Deficiency and Stasis

First, I look for signs of Blood deficiency. If Blood is deficient in general, we can safely assume that the brain is not receiving its fair share. This is a common pattern in elderly or chronically ill patients who may be nutrient deficient. In this case, we may look to a formula that builds Blood and strengthens the Spleen and Stomach, such as Dang Gui Jian Zhong Tang, to help with nutrient assimilation.

If Blood deficiency is evident but digestion is strong and the patient is suffering from tremors, we can use formulas that build Blood with a focus on Liver Blood. When Liver Blood is deficient, Liver Wind can develop to fill the hollow space left in the vessels. This can contribute to tremors, dryness, and contraction in the sinews. By filling up the vessel with blood, the internal Wind can be expelled. For tremors with cold contraction of the limbs and Blood deficiency symptoms, you can consider Dang Gui Si Ni Tang to nourish and warm Liver Blood and encourage peripheral blood flow. You may modify the formula to expel Liver Wind more directly by adding Shen Jin Cao as well, especially if there is a degree of Dampness present.

Next, is blood circulating freely, or are there signs of Blood stasis in the body? If we identify signs of Blood stasis, we want to treat this pattern gently, to ensure blood can move as it needs to. It is important to avoid treating Blood stasis aggressively in fragile patients though, and to be mindful of contraindicated medications or bleeding disorders that may be present in your patient.

Dang Gui Si Ni Tang, again, is my favorite gentle Blood-building and Blood-moving formula that can be considered for both applications. If your patient has poor peripheral blood circulation, cold hands and feet, this is a good formula to consider. You may also consider adding gentle doses of Chuan Xiong, Mu Dan Pi and Tao Ren to further move Blood stasis and support vessel elasticity.

Hou Shi Hei San is another classical formula that we should consider for patients with a history of wind-stroke, signs of Blood deficiency, possible hemiplegia, paralysis, tremors, confusion, or cognitive impairment. “Hou Shi Hei San treats great wind with vexation, heaviness of the limbs, aversion to cold and insufficiency of the Heart”, according to the Jingui Yaolue.

Yang in Blood

We also want to ask ourselves if the Blood is as full of Yang as it should be. A Yang-deficient patient might feel cold easily, have a tendency to contract inward in their posture or limbs, have signs of excess fluid retention in the body, and feel some relief with the application of heat to the body. We know that Yang is generated by the Heart (Imperial Fire) and that Yang should be traveling through the bloodstream down to the Ministerial Fire, where it is then distributed to the organs of the middle and lower jiao.

If we see signs of Yang deficiency, we must then ask ourselves, 1) is this a Heart Yang deficiency, in which the entire body is lacking Yang because the Heart is not able to generate enough, or 2) is the Heart making enough, but Yang is flaring upward and failing to descend into the middle and lower jiao? If it is a failure of Yang to descend, we will see signs of heat above the Heart and cold below. This may look like signs of Spleen and Kidney Yang deficiency, but with thirst and some mild heat or redness in the head and face. On the other hand, if it is a Heart Yang deficiency, we will see signs of systemic cold without heat signs above the Heart.

Kidney Yang deficiency in elderly and chronically ill patients is very common, and we need to focus on getting enough Yang into the bloodstream and then into the Kidney domain in order to have a positive clinical outcome with brain-related symptoms. To best help these patients, we need to get to the root of their Kidney Yang deficiency. We need to either strengthen Heart Yang and then send it down into the Kidney domain or, if the Heart Yang is strong enough but flaring upward, we need to help it descend and send it to the Kidneys.

For patients with Kidney Yang deficiency, particularly if there are also water retention or urinary symptoms, consider target="_blank">Jin Gui Shen Qi Tang. This will gently build Heart Yang too, but with an emphasis on sending it to the Kidneys. If the Yang is failing to descend and there are signs of heat above the Heart, but cold below, you can add Long Gu and/or Mu Li to target="_blank">Jin Gui Shen Qi Tang to help anchor Yang in the lower jiao. These minerals will also help to settle Shen, which can be agitated when weak Yang is flaring upward, a kind of “Fire assaulting the mind” pattern.

(Something to note about target="_blank">Jin Gui Shen Qi Tang is that while it is a very important formula for these patients, it contains Sheng Di Huang, which can be very cloying and difficult to digest for depleted patients or those with digestive impairment, so you may need to consider treating their digestive system first, then going back and address the Heart/Kidney Yang deficiency. Alternatively, you can reduce the amount of Sheng Di Huang in the formula by half, and/or add Zhi Shi or Bai Zhu to the formula to help descend the digestive Qi and support healthy digestion and bowel elimination.)

For Heart Yang deficient patients suffering from internal Cold, Si Ni Tang is a formula to keep in mind. This may present as diarrhea, pain, and cold and hypertonicity of the limbs. If there is a strong Blood deficiency or Dryness component to this pattern, you can use a combination of Dang Gui Si Ni Tang and Si Ni Tang to also build blood.

Yin in Blood

Lastly, when it comes to the amount of Yin fluids in the blood, we want to assess if the blood is a free-flowing liquid, as it should be, or if it is too dry or thick. Blood is made up of liquid and solids, and the liquid part, plasma, is around 92% water. This water makes up about 55% of our blood, so for good circulation it’s important to make sure enough fluid is available in the body. If blood is too thick and lacking Yin fluids, circulation will be sluggish, and symptoms of dryness and inflammation (False Heat) will occur. We can call this a Yin deficiency pattern, but we want to look more deeply into what’s causing the lack of Yin fluids in order to treat it. Often practitioners want to simply prescribe Yin nourishing herbs, and while these herbs can be a helpful Band-Aid or small part of a formula for some patients, they are often very cloying and difficult to digest for elderly or depleted patients, and if used alone, they will not get to the root of their pattern.

Hydration and Inflammation

A study examining the hydration status of 2,506 adults over age 60 found that women with inadequate levels of hydration showed worse performance on cognitive tasks related to attention and processing speed (Bethancourt, H.J., Kenney, W.L., Almeida, D.M. et al., 2020). According to the Dent Neurologic Institute (2022), about 75% of the brain is made up of water, and as such, dehydration and lack of electrolytes can cause acute changes in memory and cognitive performance. This is particularly evident in populations with less cognitive reserve (Pross, 2017).

We know that a lack of Yin fluids can create a false heat pattern, which essentially means that dehydration triggers an inflammatory process. Inflammation within the brain can have acute and long-term effects on cognitive function. Studies show that neuroinflammation over time is associated with the risk of dementia and cardiovascular pathology, including stroke (Sartori, et al., 2012). If the patient is presenting symptoms of neuroinflammation, we should ask: Where is the inflammatory heat coming from?

Hydration and Floating Yang

When we see Heat in the Upper Jiao drying out fluids, we might often assume the cause to be excess Heat that needs to be cooled, but in the aging population it is very rare that Heat is due to Excess. More commonly, we will see those signs of Heat above and Cold below: Yang that is too weak to strongly anchor in the Kidney domain, and as such is floating to the Upper Jiao.

(This can look like what might be called Yin deficiency by some, but clinically I find that we achieve better results for these patients if we focus on descending and anchoring Yang. We need to strengthen the yang and send it to the middle and lower jiao in order to keep it from overheating the upper jiao. This approach works well when we are faced with complex disorders in patients who often have a combination of seemingly conflicting patterns. Most often, cognitive decline comes with some degree of Kidney Yang and Jing deficiency, so if we erroneously identify Heat symptoms of the Upper Jiao as “Excess Heat” and prescribe herbs that cool it off, we risk further weakening the already depleted Yang, causing them to use up their Jing more quickly and perpetuating the pattern.)

I often hear from my older patients that they don’t drink much water because it causes them to urinate too frequently. In this population, this can be a problem if there are mobility or cognitive challenges that make getting to the bathroom difficult. If the patient is not drinking much water for this reason, we need to help them increase their fluid intake; and to do that, we need to make sure they are transforming and absorbing the fluid they consume. The most common cause of an overactive bladder in this population comes back to Kidney Yang deficiency. If there are signs of Kidney Yang deficiency, we want to help warm the bladder so that it can expand more effectively to hold the urine.

My favorite way to treat this pattern is with Jin Gui Shen Qi Tang, modified by adding Wu Yao and Xi Xin to drive the Yang into the bladder. I will often reduce the amount of Fu Ling and Ze Xie in the formula at first to keep urination from being excessive, but ultimately once the Yang has anchored in the Ministerial Fire and spread to the Kidneys and Urinary Bladder, and the patient is no long experiencing frequent urination, you want to keep the Fu Ling and Ze Xie in the formula to help the Kidneys do their job of efficiently pulling waste fluids out.

Another common cause of dehydration is the Spleen. This may present in two different ways, and we can easily determine the pattern based on the bowels and urination.

1. Spleen Yang or Qi deficiency will show up with the classic symptoms including lack of thirst. This can give the patient a sense of feeling “waterlogged” due to the overwhelming presence of Dampness and cause a lack of thirst. Turbid interstitial Dampness can also block the cellular absorption of healthy fluids, causing dehydration. These patients will have a somewhat normal urination that may be a bit turbid or cloudy, loose stool, feel heavy, and have a damp tongue presentation. Depending on their exact symptom profile, you may look at formulas like Ling Gui Zhu Gan Tang or Wu Ling San.
2. Spleen Constraint Dryness will present with constipation. The stool will be dry but the patient has frequent clear urination. This has to do with the dryness and tension of the Spleen being unable to transform fluid and distribute it through the body, leaving “rabbit pellet” constipation. We’ll often see excessive rumination and worry that has over time injured the Spleen. We treat this pattern as described in Zhang Zhongjing’s Han Dynasty text, Jingui Yaolue, using Ma Zi Ren Tang.

Free Flow of Qi

Next is the question of Qi: Is there enough to go around, and is it moving properly? The most relevant Qi deficiencies to identify and treat directly for cognitive decline patients will be related to the Kidneys (remember the Kidney/Brain connection) and the digestive organs. If there is a Spleen Qi deficiency pattern, for example, we want to treat this to ensure that the patient is able to digest and assimilate their nutrients and, very importantly, the herbal medicine we are giving them.

We should also determine if the pathways are open for Qi to move through the body and brain unimpeded. If the channels are blocked, what is in the way? The most common blockages are Dampness/Phlegm in the channels or Blood stasis. We want to identify the source of the blockage and use a treatment strategy that clears the way for Qi to flow freely. (Something to note in this patient population is that we may encounter scar tissue in the brain or body as a result of a medical condition, surgery, or trauma, and should treat it gently, as a manifestation of Blood stasis.)

From our perspective, Phlegm in the Channels can be a cause of physical tremors and muscle tics. This “hidden or insubstantial Phlegm” interrupts the free flow of Qi through the channels and to the tissues involved. Another manifestation of a hidden Phlegm is what we often call “Phlegm misting the mind” or “Phlegm blocking the Heart orifices”. Here, the Heart is seen as the material home of the Shen (mind/consciousness), and Phlegm is blocking the Shen from settling in the Heart. This pattern can give rise to clouded thinking, psychological and emotional imbalances, confusion, erratic or manic behavior, and cognitive impairment, all of which can be seen within a western Dementia diagnosis. In both cases, this hidden Phlegm has accumulated in the interior of the body and is interfering with the flow of electricity through the nervous system and brain, or from our perspective, is blocking the flow of Qi.

Phlegm is a clinical progression of Dampness that has become more turbid and stickier over time. We want to use an appropriate formula to clear up the Dampness from the patient’s system, generally by supporting healthy digestion and opening elimination pathways. This usually means using a formula to transform Phlegm into a more liquid form of dampness so that it can easily be moved to an exit, and strengthening the Spleen and Kidneys so they can drain that Dampness. You may consider a formula like Ling Gui Zhu Gan Tang to drain Dampness by supporting the Kidney and Spleen function. If Phlegm is particularly affecting the Heart and Shen, you may consider combining with Zhi Shi Xie Bai Gui Zhi Tang to loosen the Phlegm, make it easier to drain, and help drive it to the exits via bowels. I will often add herbs that help to clear Phlegm from the sinuses too, which, in Chinese Medicine, we think of as opening to the brain. For this, I will consider Shi Chang Pu, Zhu Ru, Tian Nan Xing or Bai Jiang Can. Gua Lou Shi and Xie Bai can be added to the chosen base formula for the purposes of “liquefying” sticky Phlegm as well.

Once excess Phlegm is cleared out, you want to reassess and identify whatever deficiencies are left and put the patient on an herbal formula to build them up. Remember, we always want to clear out excess before we rebuild what is lacking.

Case Study and Herbal Formula Selection

Once we identify the general pattern(s) that are contributing to the patient’s condition, we want to prioritize treatment of these patterns. We then want to choose a formula and modify it to be most beneficial to our patient at this current time.

Consider an elderly patient who has been diagnosed with Parkinson’s disease with dementia by their physician. From a Chinese Medicine point of view, we can expect them to present with multiple patterns that need to be treated. This patient experiences tremors and some rigidity of the limbs, an unsteady gait, worsening confusion, memory loss, timidness, ruminating thoughts, fatigue, low appetite, nausea when eating, feeling cold, dry skin, constipation, bloating, and thirst. They avoid drinking much water because it causes them frequent urination, sometimes with urinary incontinence, and they require assistance with safely getting to the bathroom. Their tongue has a thick white coating on it and is generally pale, but relatively unremarkable.

We can identify multiple patterns here:

• Blood deficiency
• Kidney Yang and Jing deficiency
• Spleen constraint
• Liver wind

The first step is to strengthen digestion by addressing their Spleen. When the bowels are chronically blocked, it is common for Stomach Qi to revert, as it is not descending and emptying the large intestine, which can cause nausea and lack of appetite. I would begin with for warming and building Liver Blood and supporting peripheral blood circulation. To this, I would add a modified Shen Qi Tang to build Kidney Yang and strengthen the urinary function. I’d add Wu Yao to further anchor the Yang in the Kidneys and help with the overactive bladder symptoms. In Shen Qi Tang, I will reduce the amount of Sheng Di Huang to make the formula less cloying and easier to digest, given their history of sluggish digestion. The formula might look something like this:

• Dang Gui 9
• Bai Shao 9
• Gan Cao (zhi) 6
• Tong Cao 6
• Gui Zhi 9
• Xi Xin 9
• Da Zao 15
• Shan Yao 9
• Di Huang (sheng) 9
• Fu Ling 6
• Fu Zi 3
• Ze Xie 6
• Mu Dan Pi 9
• Wu Yao 9

Over time, this formula will strengthen the ministerial fire, supporting Yang and Blood flow to the organs of the middle and lower Jiao, with emphasis on the Kidney and Spleen function. It will help build Blood and ensure there is enough Blood flow to the periphery of the body. As Blood builds, it will expel the wind filling the vessels and causing the tremors. As Kidney Yang builds, the urinary frequency and urgency will subside, allowing the patient to drink more water and become better hydrated, reducing inflammation. The Yang moving through the Kidney channel will strengthen as well, supporting a stronger gait and strengthening the lower limbs. This may be a long-term formula for this patient, given the degenerative nature of their disease, but we would want to reevaluate every few months to ensure that we are still treating the appropriate pattern.

Conclusion

In conclusion, the principles of Chinese Medicine offer a valuable perspective for addressing cognitive decline and neurodegenerative disorders in the aging population. The foundation of Jing, which resides in the Kidneys, plays a vital role in nourishing the brain and supporting cognitive functions. Recognizing the interconnectedness of bodily systems, particularly the Kidney-Brain connection and the role of the Spleen, allows practitioners to tailor treatment strategies that target underlying patterns of imbalance. By addressing factors such as Blood deficiency, Kidney Yang and Jing deficiency, Spleen constraint, and Qi blockage, customized herbal treatments can provide invaluable symptom relief. Emphasis on digestion, hydration and distribution of nourishment is crucial to treatment outcome. The clinical Chinese Medicine approach presented here demonstrates how integrating customized herbal medicine can enhance the quality of life for individuals dealing with cognitive impairment. Through the application of these principles, practitioners can guide patients on a journey towards improved cognitive function and overall well-being, bridging the wisdom of Classical Chinese Medicine with modern healthcare needs.

References

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• Burket, J. (2022, August 17). 22 facts about the brain. Dent Neurologic - Center for Neurologic Excellence. https://shorturl.at/dkpD1
• Cammann, D., Lu, Y., Cummings, M. J., Zhang, M. L., Cue, J. M., Do, J., Ebersole, J., Chen, X., Oh, E. C., Cummings, J. L., & Chen, J. (2023). Genetic correlations between alzheimer’s disease and gut microbiome genera. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-31730-5
• Pross, Nathalie. (2017, June 15). Effects of Dehydration on Brain Functioning: A Life-Span Perspective. Ann Nutr Metab 70, (Suppl. 1): 30–36. https://doi.org/10.1159/000463060
• Sartori, Andrea C.; Vance, David E.; Slater, Larry Z.; Crowe, Michael. (2012, August). The Impact of Inflammation on Cognitive Function in Older Adults: Implications for Healthcare Practice and Research. Journal of Neuroscience Nursing 44(4): 206-217. https://doi.org/10.1097/JNN.0b013e3182527690
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• Zhang, ZJ. (2012) Jingui Yao Lue Essential Prescriptions of the Golden Cabinet. (Transl. Wiseman, N. & Wilms, S.) Paradigm Publications, Taos, New Mexico.