2007年8月20日 星期一

The Geomedicine of TCM

Environmental inpact on diagnosis and treatment in TCM

Sun Si-Miao in the Qian Jin Yi Fang states: Although remote areas provide a good environment, the traffic is difficult to handle for a single person, and as soon as many people live there, it becomes noisy and complicated again. One should better live near human settlements, with a wide view and even grounds, mountains behind and water in the front, with the fresh cool air of higher altitudes, fertile ground, and some springwater around. If one can get 10 Mu plain land of this kind, one should live there.
If some has the chance to get more, it should not exceed the size of 20 Mu. If one ones a larger place it will lead to some worries, or if it becomes big like a farming ground for business it will elead to some more troubles. If this ground has some mountain ranges to the left and right and lies in between, it is an ideal ground. If the place for living is chosen well, one will live in harmony, and what else does one need more ?"

In regard to ethnomedicine, some voices stick to the absurd opinion that a medical system like TCM can not be applied to other cultures at all, but the high efficiency of TCM in western patients proofs them wrong. On the other extreme there are a few American therapists, who claim having developed an "new school" of acupuncture and thus completely reject the Chinese approach of TCM to systematic treatment as done in China. This leads to the question: How much do Chinese patients und their counterpart in the West actually have in common?

Recently some reports have been published by Chinese Doctors prakticing in the West. For instance Hu Jinsheng proposed in the World Jounal of TCM that his German patients have a special kind of Migraine, differing from his patients at home. He relates it to the sleeping habits, the weather and the stressfull society in Germany. In another article Yang Deli and Liu Jiaying describing their experiences in Germany notice the high rate of allergic reactions which they relate to the working situation, the fast lifestyle and the struggle in the socitety. All authors report these differences but also that their patients responded very well to the treatment with Chinese medicine. This raises another question,which is: If western and eastern patients have enough in common for receiving good results with Chinese medicine, how much adjustment to the patient is really necessary ? Is the time and space of a patient and his therapist of importance for the treatment or can it be negletcted ? This article is trying to look into these and related questions.

The century old Chinese medical classic Huang Di Nei Jing (Inner Classic of the Yellow Emperor) emphasizes space and time of health: Not only does it tell about diseases and treatment in relation to seasons, hours and periods, leading to the later emphasis of the febrile diseases school on time-related treatment and the Zhi Wu Liu Zhu chronobiological acupuncture method, but it also emphasizes treatments and diseases of different places. Since we life in both, time and space, the loudly touted "individualistic medicine of the 21. Century" (WHO) should concern both influences on the human body. Some attempts have already been made to find links between chronobiology and TCM (i.e. see my article: Schlaf als Schlüssel zum Alterungsprozeß, Zeitschrift für Traditionelle Chinesische Medizin, Vol. 7–1/98), and several books in China and abroad which cover the topic "relations between time and treatment" (see reference list).

Concerning space, western biomedicine has only a few years ago found a new branch of environmental medicine, which researches harmful influences of the environment to the body. But approaches to a wider view of connections between location and health as in geomedicine have been very few so far. The great medical Online-Library MEDLINE lists just two abstracts, and although the ancient chinese geomantic literature (Feng-Shui) is full of hints about ideal places to live, it says little about the effects of the environment to health and the necessesary adjustments of the therapist to these differences. Again the taoist doctor Sun Si-Miao (quoted above) relates to this in his other book the Lue Ji Qian Jin Yao Fang: "The rooms of ones living quarters should be tight, without any small cracks through which the wind can enter. (…) When taking a bath the room must be sealed well, such preventing heat or cold to enter, or else it will lead to many diseases."

This again regards to the direct environment and its influences, but climate, nutrition and the greater invironment have different effects on the individuum, too.

In the taoist book Guan-Zi, said to be dating from the Han Dynasty (2nd Century BC-2nd Century AD), many connections are drawn about the water quality and local inhabitants characters: "The water of Chu (Hunan) is soft, weak and pure;thus the people are light-hearted and self-confident. The water of Yue (Guandong) is turbis and heavy, soaking through the lang,; thus people are foolish, unhealthy and dirty. The water of Qin (Shanxi) is full of sediment, muddy and clogged with dust; thus this people are greedy, deceptive and given to machinations. (..) The water of Yan (Hebei) collects in low places but is weak, slow-moving and turbid; thus its people are simple, chaste, quick and willing to lay down their lives."

Later it relates the quality of the local soil to the inhabitants' constitutions and personalities: "Men who live in places where the earth is solid grow fed, those who live on loose soil are tall, those who live on sandy soil are thin. Fine looking men are produced from places where the earth is fertile, but a poor soil breeds ugly ones. "

Even more information is available from the Nei Jing (Inner Classic of the Yellow Emperor), which describes these realtions in detail:

"The East produces fish and salt, having a warm climate and receiving Qi from heaven and earth. People living near the shore like eating fish and a salty taste, but too much fish causes heat in the body, and the salty taste can consume the blood, so they have a dark skin and a loose texture. This is why the stone needle (for blood-letting and release of pus) was coming from the East, since most common diseases are of the exterior like abscesses.

In the West there are mountains, wilderness and a desert, bearing precious stones, the environment is stringent like weather in the autumn. The people live in stable houses on the hills which can endure the strong wind and tough water and earth conditions. Those people live a plain life in terms of clothing and sleeping, wearing cotton clothes and sleeping on grass mats, but their food is rich and abundant consisting mainly of meat. Since they have strong, obese bodies external diseases invade them seldom, but they often suffer from internal diseases, which can be cured by herbs. This why herbal medicine cam from the west.

In the North, the high terrain is like winter, so people beneath mountains often encounter a cold climate with ice or storm. They live as nomads in temporary houses and drink milk from cows and sheep. They often suffer from the invasion of cold and difficult digestion, so moxibustion came from the north.

The Qi of Yang is strong in the flourishing, warm climate of the South, which is summer-like bearing fog and dew in its low, humid areas. The people here are used to sour and fermented food (due to the temperature) and their skin is bright and red. They are often affected by diseases like stiffness, cramps and stiff extremities. These are suitable to be cured with needles, so the classic nine needles came from the south.

The climate in the middle areas is rich in resources, mild and humid. So people live a quiet life and eat many kinds of (sweet) food. So the common diseases here are atrophy, contravective Qi and fevers. For these Daoyin (kind of early Qi-Gong) and Anqiao (kind of Tui-Na massage) are effective. Therefore Daoyin and Anqiao came from the central plains.

Therefore a skillful doctor can select and combine all methods, according to the patient’s needs."

An even earlier work from the Warring states period around the 3rd century BC, Lü Shi Chun Qiu lists more connections between the environment and its inhabitants and sum it all up in: "If nutrition and dwelling are suitable, the nine orifices, hundert joints and thousand vessels (of the body) will all be unrestricted and healthy."

Modern resarch has also proven, that local variants of plants contain different substances, like our Glycyrrhiza glabra and the Chinese Glycyrrhiza uralensis. Less known is the fact that even samples of exactly the same species grown in different araes show significant differences in their ingredients:
Chinese Glycyrrhiza uralensis coming from six places in China with different soils contained strong variances in their organic and inorganic chemical components. This is even more true for animals and therefore for man as well. If we consider these influences to have an impact on ones constitution and health, it must have consequences for the therapist when diagnosing and treating his patients, too.

During my stays in Taipei, Kunming and Tianjin I tried to confirm this by observation and was finally able to verify the Nei Jings’ old wisdom about "other places – other diseases":

While the temperature on the island of Taiwan is rather high (between 10 and 40 degrees centigrade), it is even more surpassed by the degree of humidity, which is the whole year long around 90-95 degrees. The people eat rich, plentiful food, with a tendency to sweet or bland tastes. Besides the high rate of asthma in children, definitely increased by the high air pollution, I encountered many metabolic inner diseases like diabetes or rheumatic diseases.
From the view of TCM, many pattern syndromes were related to phlegm and moistness, due to the harm done to Spleen by nutrition and climate. The therapies in Taiwan are nowadays varied and plentiful as everywhere in China, with a local tendency to bloodletting, Gua-Sha (scratching) and a slight prevalence of Qi moving herbs, which connects again to the treatment of moistness and phlegm. Since most of the asthma cases were connected with allergic reactions, and the modern TCM links the immune system to the Spleen, some thoughts need to be given to this connection, too.

Kunming, the capitol of the Yunnan province lies also on a plane, but this is about all it has in common with Taipei: The temperature is constantly mild in all seasons (between 16 and 26 degrees centigrade), but the air is very dry with 35 degrees humidity, slightly higher in the summer season. The natives eat very spicy, adding chilies to almost any dish, such preferring a hot, spicy taste.
The most common diseases I saw, were diseases of the respiratory and digestive system, with a high rate of cancer in the terminal segments of the colon. Besides Large Intestine diseases, TCM can observe here the typical Yin deficiency syndromes of the Lung and Stomach, as well as Wind-Bi in older people.
This is said to be due to the dry climate as well as the spicy nutrition. The use of high doses Aconite (Fu Zi Pian) as an ingredient of soups in the winter time is common practice in the local seniors, which also leads to pathogenic dryness. Concerning therapy, the herbal garden is virtually overflowing here, with lots of only locally known herbs, but there is clearly a prevalence of Yin nourishing herbs, which relates again to the prevalence of Yin deficiency and dryness in Yunnan.

Tianjin, Chinas third largest city and major northern harbour, has an extreme climate with hot summers and cold winters (between –6 and +40 Centigrade degrees), while the air is rather dry, between 18 and 40 degrees humidity. Locals previously ate rather plain food, but very salty. In the recent decade fish and meat consumption has strongly increased, while the salt intake is still very high. The water contains a high amount of calcium. Due to these factors, Hypertension and strokes are very common, as well as coronoary heart diseases and other circulation related illnessses. In TCM the salty nutrition also harms the kidney. Extreme heat and cold as it annually occurs here, can lead to bloodstasis.
This may explain the common occurence of the bloodstasis syndrome, as well as the prevalence of wind-strokes even in many middle-aged patients, which is due to Liver-Wind or ascending Yang, and based on Kidney Yin deficiency. Postapoplectic hemiphlegia is treated mostly with acupuncture and bloodstasis with blood invigorating herbs like Radix Salvia (Dan Shen) which grows wild in the local plains.

Obvious diagnostic features like many greasy tongues in Taipei, dry and shrunk ones in Kunming and purple ones with stasis spots in Tianjin were also showing the typical features of the local syndrome/disease tendencies. These experiences with patients from different areas in China clearly hinted that the wisdom of the Nei Jing should not be ignored.

It also should clearly indicate a necessary adjustment to the body and the disease of the western patient, who lives even farther from the land of the Nei Jing. But since my own observation was only brief and therefore could be exeptional or biased, I tried to confirm it with the help of many Chinese doctors, since Chinese medicine emphasizes the close and individual observation of the patient. Listed below, are some of those results:

In his private East-west clinic in Taipei, Chang Chung-Gwo, now the chairman of the COMMITTEE ON CHINESE MEDICINE AND PHARMACY DEPARTMENT OF HEALTH EXECUTIVE YUAN, R.O.C. in Taiwan has treated hundreds of western patients from Germany, France, Switzerland, the USA, Israel and other countries during the past twenty years. Most of them were members of the foreign business community, but I could also observe a couple of patients who came flying especially in from Israel or France for a visit, and went straight back to the airport after their acupuncture treatment, taking the herbal prescriptions for the next few months with them. What made TCM so attractive for them, that they were willing to spend time or money for this treatment ?

Dr. Chang said that most of them tried western medicine in vain and came to TCM by a recommendation of a friend. Common complaints were pain, spine problems, arthralgia, arthritis, and so on, but a lot were coming for infertility, asthma, allergies as well as for treatments to stop smoking or reduce obesity.

As for the effects, Dr. Chang stated, that the therapeutic effects usually surpass their Chinese counterparts, since the local patients have a lower compliance, while the Westerners have a stronger constitution and their body is not used to Chinese herbs from childhood on. I could confirm this observation during two years of apprenticeship in his clinic in the early nineties. So far no differences among patients from different western countries were noted, which might be due to the fact, that most of them were living in Taiwan at this time.

Dr. Lin Yun from Tianjin has been to France in 1990 and 1991, working with acupuncture in a hospital in cooperation with the local physicians. Regarding her own feeling during the needle insertion, western patients’ skin is not basically different from Chinese patients, but while all patients had a feeling of "De Qi", it was expressed in other words than the usual Chinese definition "numb, swelling or sore", describing it instead as "electric, strange, or even painful". Most of them wrote in the query following the treatment that they felt very relaxed or "fatigue" (tired). Interesting is also, that even patients, who knew nothing about the course of the channels, described the feeling of "something" (Qi?) moving along under their skin in the channel direction.

Dr. Wu Gao-Lin from Tianjin has been treating German patients in a small town in the north of Germany, with both, acupuncture and herbal prescriptions. "The Germans are very co-operative and keep strict to their prescriptions, which is very helpful", she said. According to her experience the efficiency of both treatments has been higher than in her homeland. "Maybe there is a psychological factor involved," she said to me, "if you treat patients in Germany, having a Chinese face is definitely an advantage…". She also found that male patients are often more sensitive to the pricking of the needle, in comparison to the female Germans. Some also find the herbal prescriptions hard to swallow, especially if they contain bitter herbs. Nevertheless, most of them show good effects and they are willing to come back and often bring friends and relatives. "I once succeeded in the treatment of stomach cancer of a truck driver, who had no time to go to a hospital and stay there for an operation. I really thought this was above my skills, but I tried hard since I was his only hope, so I thought quite a while about his case and how to keep the price low enough for him (since Chinese herbs are very expensive in Germany). Finally I developed a combination of acupuncture and herbs on a regular basis. I was really surprised, that after a few months he brought me the new report from the hospital, stating that he no longer needed an operation."

Dr Wei, also from Tianjin, has been in Germany at the same place as Dr. Wu for more than one year. He used acupuncture and Qi-Gong as main therapies. He found, that Germans have a thicker skin than Chinese patients, but are more sensitive to pain. Since most patients are used to the common practice of inserting the needle and applying no twisting or other manipulation, he found, that most patients had to become slowly aquatinted to this feeling, which is different to what is experienced with local German acupuncturists, who use thinner needles and no manipulation techniques. But all of them were very fond of his Qi-Gong training, finding it very worthwhile to learn and experience.

TCM-Doctors from Kunming in Yunnan have been treating Spanish patients in Barcelona, Tarragona and Madrid for many years. Among them Dr. Xia Hui-Min, the famous head of the "Tui-Na-Department in the Yunnan TCM-Hospital" using acupuncture, Tui-Na and herbal prescriptions on more than thousand patients. Dr. Xia said, it was a pity, that most patients did not know how well his kind of massage works for the "frozen shoulder-syndrome" in the elderly, even better then acupuncture when the shoulder joints are already connected. Since most Spanish patients thought it a kind of common massage, they massively underestimated it. Another obstacle was the belief, that physicians having a higher status than a physiotherapist, and therefore do not touch or massage their patients.

Dr Zheng Jin, the head of the TCM faculty and former head of the diagnostic department in the Yunnan College of TCM wrote down many of his experiences during his three-year stay in 1995 to 1998 with more than 1000 Spanish patients:

Physical constitution: Since in Chinese males the body structure is built stronger than in females, the physical constitution is stronger biased to the Yang/Heat nature, while in female Chinese the physical constitution tends more to a Depletion/Cold nature. In the observed western Patients the difference between male and female patients was less, since in both sexes a tendency to Yang/Heat syndromes could be found equally.

2. Diagnosis - In Chinese traditional diagnosis the following differences were found:

While in Chinese male Patients the pulse had a stronger tendency to pulses like the excessive, big, long and stringlike (wiry) pulse, in Chinese female patients it more common to find pulses like the deficient, weak, soft and short pulse. Also this difference could not be found in significant numbers in his western patients, who both had often excessive (full), slippery, stringlike (wiry) pulses.

Although the facial color of "white" people tends to be more white than in Chinese, there is still an amount of yellow present, which relates to the normal expression of the stomach Qi. Therefore individual physiological skin colors and pathological skin changes to red, yellow and white, can be observed and interpreted in the same way as in Chinese patients.

The fact, that in western patients the bone structure is built stronger and the muscles and flesh is usually fuller than in Chinese stands for a stronger development of the spleen and stomach function (which govern the flesh and muscles) and the kidney qi (bones).

Since a higher ocurrence of strong body odors was noticed in many Spanish patients (which might be due to a diet which comparatively higher in animal proteines and climatical influences) the presence of damp-heat can be assumed to be more common in this area of Europe.

In regard to the answers of the patients during the diagnostic inquiry, local patients in Spain had none such habits as paying detailed attention to i.e. color, shape, smell of their excretions or body fluids like phlegm, urine or faeces and did not discriminate between preferences in eating or drinking i.e preference of hot beverages over cold ones or aversion against cold foods, as comon in China. Thus the inquiry needs to be adjusted to these habits or their absence.

Diseases: The following diseases occurred more often in Spain than usually found in China: Depression and other mind-related diseases, psoriasis, neurodermitis and other skin diseases and allergies, as well as hepatitis C and sexual diseases.

Syndome patterns: The following diseases occurred more often in Spain than usually found in China: emotional related stagnation of the liver qi (gan qi yu jie), deficiency of the kidney, internal accumulation of phlegm-heat (tan shi nei zhu). Besides that, in many of the Spanish vegetarians syndrome patterns of spleen-stomach deficiency or Yang-qi deficiency were found.

Therapy: It appeared, that western patients responded more sensitive to the needle sensation in acupuncture as well as to the effects of herbal medicine prescriptions. Therefore it is recommended, to have patients always lying down during acupuncture in oder to prevent psychogenic shocks, besindes the manipulation of the needle should be less strong than in China and the dose in the herbal prescriptions can be reduced until they are adjusted to the patients reaction.

These experiences of Chinese doctors with patients from Europe hinted not a few necessary adjustments to the different cultural background, nutrition and life-style habits, environmental and climatical influences and maybe even to genetic differences.

They felt, that Chinese medicine - from acupuncture and Tui-Na-Massage to herbal prescriptions and Qi-Gong - was applicable to non-Chinese patients, but also noticed some differences in the diagnostic expressions of the diseases as well as in the reaction to the treatment. They all were quite satisfied with their remarkable success, which seemed even surpass their experiences at home. Thus the question whether TCM is recommendable to western patients seems to be a definite "yes." Still, we have to ask us questions about some necessary adjustments like these:

Herbs: If the acupuncture insertion depth is reduced - as many western books recommend - to which degree can the dosage of the prescriptions also be reduced, achieving the same results ?

Acupuncture: When are strong manipulation techniques indicated – as applied in China for hemiphlegia etc. and how can they be reduced for sensible patients, achieving the same results ?

Diagnosis: What are the differences in the appearance of syndromes and symptoms in western patients, compared to what is found in China ?

General treatment: Which diseases are more typical in western countries, differing from China in terms of nutrition, weather conditions and genetics – and how can the treatment be adjusted to the maximum therapeutic effect, as described in the Huang Di Nei Jing (Classic of the Yellow Emperor) ?

Geomedicine: To which degree do we need to distinquish between patients from different countries or even locations in their county ? If i.e. prevalence of damp-heat is typical in Taiwan and in Spain, how about England, France and Germany ?
The question about the necessary degree of adjustment in TCM to the western patient seems to present a problem that can not be solved by observation only. Nevertheless, it is our generation which is technically and by present knowledge able to make such a pioneering effort to find an optimum adjustment of Chinese medicine to non-Chinese patients, in this way paving a road in ethnomedicine and geomedicine. Those results can even provide principles for other medical systems (India, Tibet, etc.) with the potency to merge with or contribute to a future medicine for all mankind.

For this reasons the research of variations and congruity between the diagnostic results and reactions to treatment with TCM has been chosen by Dr. Yeh and myself as a new research ground and content of our doctoral thesis. Since the Chinese government has given full support to this field of research, the clinical studies following the theoretical foundations of this research will begin in 1999 in both continents, Asia and Europe.